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.