Until the emergence of coronavirus disease 2019 (COVID-19), tuberculosis (TB) was the leading infectious cause of global morbidity and mortality worldwide. While the number of people falling ill with TB has been steadily declining in recent years, disruptions caused by the COVID-19 pandemic has reversed years of progress in the fight against TB according to the 2021 Global TB Report.
In 2020, there was an estimated incidence of 591 000 TB cases in the Philippines. However, only 44.5% of cases were notified. A drop of 37% in the number of notifications in comparison to the previous year (419 102 cases in 2019 versus 263 300 cases in 2020) reflects how COVID-19 affected the continuity of TB services.
In 2020-2021, the Philippines stepped up its efforts to curb the spread of COVID-19 by implementing lockdown measures and repurposing healthcare personnel. Simultaneously, health authorities collaborated with key stakeholders, including the WHO Country Office in the Philippines, to ramp up and adopt easy-to-implement solutions to mitigate the impact of COVID-19 on TB services. Two priorities were to 1) ensure that TB diagnostic networks remained functional and 2) maintain access to anti-TB treatment. WHO supported the Philippines with this work in line with WHO’s vision For the future: towards the healthiest and safest Region and thematic priority of improving health security. “For the Future” provides an outline of how WHO in the Western Pacific Region will achieve global strategic priorities and includes new ways of working such as using innovation and partnerships to achieve its long-term vision.
How did the Philippines do it, and how did the WHO Secretariat support the Philippines?
In line with activities outlined in the updated Philippines Strategic TB Elimination Plan for 2020-2023 and the “For the Future” vision of using innovation as an operational shift, the WHO Country Office in the Philippines collaborated with the Department of Health and other partners to develop and launch a package of digital solutions called the "End TB AppSuite”. These applications aim to improve the efficiency of specific tasks and help address challenges, particularly data collection and under-notification of TB cases. In addition, the End TB App Suite helps monitor and improve TB treatment adherence and assists in keeping patients on their treatment plan.
Efforts to strengthen the laboratory network followed recommendations obtained from several WHO missions working through a one team approach, a WHO-led study tour of mid-level managers from the Philippines to South Africa, and TB diagnostic network optimization in collaboration with the Foundation for Innovative New Diagnostics and Llamasoft. In addition to being involved in discussions with numerous partners to improve data collection, WHO provided technical support to STRider (Specimen Transport Rider) and is leading the STRider initiative's impact assessment.
In the early stages of the COVID-19 pandemic, the country expanded molecular technologies for rapid and simultaneous detection of TB and rifampicin resistance to cover all presumptive TB cases as the primary diagnostic test. In parallel, the Department of Health pushed to maximise the use of the STRider network. The Department of Health co-manages the network with the Philippines Business for Social Progress through a Global Fund TB grant. This network is a specimen referral and transportation system established to address the lack of reliable transport mechanisms between TB laboratories and rural health units and was designed as part of the patient-centred diagnostic network. Although initially introduced in 2018, the country heightened its efforts to expand the network following the emergence of COVID-19.
During its inception, the STRider network relied on 138 motorcycle riders to connect 1048 rural health units with 127 expert sites in seven of the 17 regions in the Philippines. Between 2020 and 2021, the network expanded to cover all regions comprising 350 STRiders assigned to 2705 rural health units, including health centres and barangay health stations, 281 government hospitals, and 202 private hospitals. Additionally, STRiders also played a critical role in transporting biological specimens to diagnose HIV and support the provision of treatment for those living with HIV by covering 117 HIV treatment hubs and social hygiene clinics. The STRider network also covered 24 facilities providing COVID-19-related services.
Photo Credit: © WHO Country Office, Philippines
Photo Caption: STRider delivering a sputum sample for testing to the Departmental of Health regional office in Tuguegarao, Philippines.
Since the onset of the pandemic, STRiders transported approximately 300 000 specimens for the diagnosis of TB. STRiders also helped reduce turnaround time from specimen collection to treatment initiation. They provided more than 10 000 packages of TB medicines to patients, enabling them to take their medications at home rather than travelling to overburdened health care facilities.
The STRider network helped many TB, HIV and COVID-19 patients who otherwise may have faced significant challenges and costs to access care or may have delayed or missed care entirely. In other words, STRiders have contributed to keeping patients within their care pathway, ensuring that the health system provided timely diagnosis and treatment despite the stresses and strains that the COVID-19 pandemic caused.
A recently published TB patient cost survey showed that 42.4% of TB-affected households in the Philippines faced catastrophic costs due to TB [1]. The total TB patient costs in the Philippines were primarily due to direct non-medical costs such as transportation expenses and the economic burden expressed in terms of time lost travelling to and from health facilities as well as time spent at the facilities. By collecting sputum specimens from the nearest sputum collection centres and delivering treatment packages to patients in their households, STRiders help bring down catastrophic costs. Presently, the WHO Country Office in the Philippines continues to work with the Department of Health to assess the impact and scale-up of the STRiders network and determine how to progressively include other disease programmes into the network to implement the Universal Health Care Act.
The COVID-19 pandemic posed unprecedented threats and further exacerbated challenges related to ensuring access to TB testing and detecting TB cases. While TB notifications decreased compared to previous years and the long-term effects of COVID-19 on TB outcomes are yet to be unveiled, the Philippines, with support from WHO, identified approaches for sustainable operations (for example, leveraging existing networks to keep essential services operational) and to help build resilient health systems. Improving access to TB testing services and supportive care remains a priority and will continue to be improved in order to continue advancing the “For the Future” vision.
REFERENCE
[1] https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0264689
Photo Credit: © WHO Country Office, Philippines
Photo Caption: STRider on his way to deliver sputum samples to the Department of Health regional office in Tuguegaro for testing.
