Letter from the Philippines

The Philippines has a high burden of tuberculosis (TB) with around 1 million active cases. In 2019, prior to the coronavirus disease 2019 (COVID-19) pandemic, the Philippines ranked fourth in terms of TB cases, with 554 TB cases per 100,000 population. TB is the second leading cause of death among communicable maternal, neonatal and nutritional diseases in the country.1 In the WHO Global Tuberculosis Report released on 14 October 2020, it was stated that the COVID-19 pandemic could reverse the gains made in TB control over recent years in many countries, including the Philippines. In addition, the 2020 WHO Report noted a drop of 50%–75% in monthly notifications for the April to June period compared to January 2020 in the Philippines.2 This is attributed to under-reporting of new TB cases during this COVID-19 pandemic. The National TB Control Program (NTP) of the Department of Health (DOH) had to make adjustments in its schedule for ongoing TB treatment. The immediate response was providing patients with a 1-month supply of an ‘all oral regimen’. Nationwide community quarantine and lack of transportation caused diagnostic delays and treatment interruption. Active TB case finding was discontinued. Restrictions on symptomatic individuals visiting health centres were imposed. Nurses in TB programmes were assigned to COVID-19-related duties and financial resources were reallocated from TB to COVID-19. GeneXpert (Cepheid) machines were diverted for use in COVID-19 testing. Any benefit from wearing of face masks and social distancing to reduce transmission of TB was outweighed by this disruption in the delivery of TB services. Because of similarities in symptoms such as cough, fever, back pain and difficulty of breathing, the recognition of TB may be confused with COVID-19. Co-infection with both diseases could exacerbate natural symptoms of the other, leading to a diagnostic dilemma. The risk of death in COVID-19 patients with TB is 2.17 times higher than in those who are TB-free. The recovery from COVID-19 in patients with TB was 25% lower than in those without TB, as reported in a modelling study done in the country.3 The DOH ‘NTP Adaptive Plan for the COVID-19 Pandemic’ was formulated to ensure that TB services continue and complement the COVID-19 response of designated facilities and service providers.4 The emphasis was on a ‘patient-centred” approach. Screening and contact tracing continued and this included patients with suspected COVID-19 and presumptive TB, based on symptoms and chest X-ray findings. There was a shift to community- and home-based treatment to minimize physical contact from frequent visits to health facilities. Follow-ups became virtual or through telephone consultations. Family members were tapped as treatment partners. TB GeneXpert testing could now be performed on a laboratory bench without the use of the biosafety cabinet, except in an already confirmed COVID-19 case. Follow-up smear microscopy was done in peripheral facilities with complete personal protection equipment. Stock inventory, reporting and training became online. The care of TB patients is not just the responsibility of the DOH. Private physicians contribute to the programme through case notification and referrals of TB patients to Private–Public Mix DOTS (PPMD) units for treatment. Health education and directly observed therapy, short course (DOTS) are among the units' main functions. These PPMD units are a private–public collaboration launched by the Philippine Coalition Against TB (PhilCAT) and DOH more than 10 years ago. These units took over the delivery of TB services as government facilities were burdened with COVID-19. PhilCAT is a 65-member non-government group established in 1994, which DOH regards as a reliable partner and a vehicle for acceptability of its TB programme both to the people and private healthcare providers. It is a leader in TB Advocacy. Largely due to PhilCAT, the Philippines is internationally recognized as the leader of the Private–Public Mix (PPM) approach, which was adopted in 2002 by the STOP TB Partnership as a specific TB control strategy. At the national level, PhilCAT leads the Annual World TB Day (WTB) Commemoration in March and in August of every year, it holds an annual conference. The lockdown imposed on 15 March 2020 in the Philippines led to cancellation of the WTB commemoration and, like every organization, PhilCAT activities shifted to online meetings. This became the venue for dissemination of the NTP Adaptive Plan to the private sector. Overall, these changes brought TB services ‘“closer to home’. The Philippine Tuberculosis Society, Inc. (PTSI), one of the PhilCAT founder organizations, conceptualized a project called ‘PET COVID’ (PTSI Expanded Tuberculosis [PET] Service Coverage to Mitigate Impact of COVID-19) aiming to ensure continuity and quality of care to TB patients. Despite the outbreak of COVID-19, PTSI aims to strengthen, intensify and expand its services to the community at large—to find, test and treat TB cases. House-to-house visits for screening, diagnosis, treatment and provision of TB care will be delivered to communities that are beyond the reach of many public health facilities. Figure 1 shows the day-to-day work of PTSI staff and local health workers. The COVID-19 pandemic has significantly affected the ongoing TB control and treatment in the Philippines. There is an even greater threat—an increase in multidrug-resistant TB. Continuity of TB services should not waiver. The potential synergies from COVID-19 and TB joint activities should be well funded. PhilCAT is hosting World TB Day 2021 with the theme: ‘Finding TB: Get Back on track!’. It's time we did! The author declares no conflict of interest.