THE Philippines has the unenviable distinction of being the fourth largest contributor to the number of tuberculosis cases worldwide, after India, China and Indonesia, with 500 people affected per 100,000 (Barriers to tuberculosis care in the Philippines by Robyn Gayle K. Dychiao and colleagues, The Lancet, June 2022).

But heres the catch: data reported by governments to the World Health Organization (WHO) show a sharp, unprecedented fall in the global number of TB case notifications between 2019 and 2020 (from 7.1 million to 5.8 million), with the largest reductions in Southeast Asia and the Western Pacific regions. In the same document — Consolidated Report of Country Success Stories in Mitigating the Impact of the C-19 Pandemic on TB Services (April 2022) — a case study from the Philippines reveals that Notification of estimated TB cases dropped from 70 percent in 2019 to 45 percent in 2020.

poster

The drop in screening of suspected TB-infected individuals resulted in a 35 percent decrease in new and relapse TB cases in 2020 compared to 2019, the Department of Health (DoH) reported. All TB-related services were disrupted due to the Covid-19 quarantine protocols.

This happened worldwide. While notifications of new cases dropped due to the lockdowns and fear of getting exposed to Covid-19 infected persons at medical facilities, TB-related deaths increased for the first time in a decade. In 2020 an estimated 1.5 million individuals died from TB, up from 1.4 million in 2019, WHO reported. In the Philippines, on the other hand, deaths attributed to respiratory tuberculosis dropped from 22,568 in 2019 to 18,457 and further, to 16,026 in 2020 and 2021, respectively (Philippine Statistics Authority). The big question is, how many deaths attributed to Covid-19 had TB as a contributory factor?

The pandemic has taken global tuberculosis control back by roughly 10 years, Keertan Dheda and colleagues conclude in The intersecting pandemics of tuberculosis and Covid-19 published in The Lancet in March 2022.

In the Philippines, the 0-24 years age bracket accounts for 27.3 percent of TB cases, while Filipinos age[s] 10-24 have also been shown to be more likely to discontinue tuberculosis treatment than those older than 24 years. Flores and colleagues in The social determinants of tuberculosis in the Philippines (The Lancet, January 2022) further point out that young people have had the steepest rise in HIV infection in the country. TB often afflicts HIV-positive persons — among the 1.5 million individuals worldwide who died of TB in 2020, more than 200,00 were HIV-positive. HIV testing and treatment have, like TB, seen serious disruptions due to pandemic-related lockdowns and difficulties in seeking medical consultations and treatment, similarly resulting in sharp drops in screening.

Despite various programs and initiatives, despite notable progress, the incidence of tuberculosis in the Philippines remains nearly stagnant, according to Flores and colleagues. The DoH in its 2019 TB Program Review — quoted by Flores — identified the particularly vulnerable populations, namely the urban poor, people living with HIV, and people deprived of liberty.

Stakeholders must recognize that at the core of tuberculosis endemicity are the socioeconomic determinants of health, and addressing these determinants is the key to ending one of the biggest health problems of the country, Flores concludes.

Is the governments TB control program giving sufficient consideration to these socioeconomic determinants? Are the TB testing, diagnosis and treatment protocols sufficiently sensitive to the factors that keep tuberculosis nearly stagnant? TB is a public health concern. It is a highly infectious and contagious disease and therefore not simply the concern of the infected person. The community has an interest in containing the spread of the disease. The good news is that TB is curable and the government is providing medication for free. Free and fast sputum testing is available, and one can get the result the same day, if processed at, for example, the DoH TB Reference Laboratory in Cebu City.

However, there are protocols that would definitely discourage suspected cases from getting tested. A friend who was diagnosed with TB last year had to go to the barangay health center every day the first week of the six-month treatment period for the health center personnel to administer the daily dose of four tablets. Patients who show sufficient interest in the treatment were later allowed to collect medicine good for a weeks consumption or even send a representative to collect the medicine. Others, however, still have to show up every day. One would think that a more hassle-free, convenient approach could yield better results in terms of more infected persons seeking and completing treatment, leading to reduction in the TB disease burden in the community.

The nearly stagnant incidence of TB cases indicates that existing approaches are insufficient. The situation worsened due to the pandemic with TB care having been impeded especially in countries with high [TB] burden, Dychiao and colleagues point out. A novel approach is now imperative, the authors conclude. We hope that the government is listening.