Guaranteed fund support badly needed
Private-public collaboration in DOTS-Plus for multidrug-resistant tuberculosis
Von Thelma E. Tupasi
The Philippines has the highest documented prevalence of tuberculosis (TB) in the Southeast Asian region. In the 1997 nationwide TB survey, the prevalence of multidrug-resistant tuberculosis (MDR-TB, meaning having TB bacilli resistant to at least isoniazid and rifampicin) was 4.3%; 1.5% in untreated patients and 14.3% in those who had had previous treatment. Extrapolated to the estimated number of bacillary cases, the estimated number of MDR-TB would be 26,082 nationwide and 2,085 in the urban poor settlements. This poses a public health emergency of global magnitude due to the prospect of potential transnational transmission.
The strategy of Directly Observed Therapy, Short course (DOTS) was introduced in the Philippines only in 1996. It is anticipated that by the end of 2001, all public health centres will have the capability to implement DOTS. It has been shown, however, that only few TB patients consult the public health centres and that more consult private health services. Thus, the private sector should assume also responsibility in TB control through a private-public partnership. The Makati Medical Centre DOTS Clinic is one such private-public partnership providing first-line anti-TB drugs.
The treatment failure rate in the Makati Medical Centre DOTS Clinic was 12% in 1997. Treatment failure was only seen inpatients with MDR-TB. Among TB patients so far seen at the clinic, 23% have been found to have MDR-TB. If left untreated, the public health implications can be disastrous. It was therefore imperative that action against MDR-TB is undertaken. As the first place in the Philippines, the Makati Medical Centre DOTS Clinic was able to start with the DOTS-Plus strategy for MDR-TB cases. This has been approved as the first pilot project on DOTS-Plus for MDR-TB by the Green Light Committee, which collaborates with the WHO Scientific Working Group on MDR-TB. This has permitted the clinic to get the expensive second line drugs at a considerably lower price.
The first patient with MDR-TB was enrolled in April 15, 1999. As of October 2001,100 patients with MDR-TB have already been enrolled in the clinic. The majority of patients (55%) are unemployed and the average monthly income is little more than US$ 100.- The monthly cost of medications range from US$ 8.30 to US$ 277.- with an average cost of US$ 80.-. Except for a few patients, most cannot pay for their medications and subsidizing treatment is therefore necessary. Drug susceptibility testing done before treatment showed that most patients have resistance to four or five of the first line anti-TB drugs. Of the 100 isolates, 80 were resistant to ethambutol, 64 to streptomycin, 45 to pyrazinamide, 36 to ofloxacin and 41 to ciprofloxacin.
Only 20 patients who have received at least 12 months therapy were eligible for interim analysis. Ten of these completed the 18 months therapy course. Two were cures, one failed and died, one failed and defaulted, another failed and was re-enrolled. Of the remaining patients, 13 were likely cures while two were likely failures. Eight of the 100 enrolled MDR-TB patients died. Seven deaths occurred prior to 12 months therapy. Seven defaulted; one defaulted after failure, and of the remaining six defaulters, two had sputum conversion prior to default. One was transferred out on the fourth month of therapy after sputum conversion.
In spite of the failures, these results are overall encouraging and indicate a potential good therapeutic response among patients with MDR-TB to the intensive therapy with the use of second-line anti-TB drugs. The procurement of the drugs for the 100 patients has been supported by the Philippine Charity Sweepstakes Office, private fundraising activities of the Tropical Disease Foundation, and from a World Bank assisted project of the Department of Health. The continuity of the funding support for this project is badly needed, as uninterrupted supply of second line anti-TB drugs is essential for the success of DOTS-Plus. However, the continuation of the funding is not yet safeguarded.
*Thelma E. Tupasi, MD, The Tropical Disease Foundation, Makati Medical Center, Makati City, Philippines.