Strategies for Tuberculosis Control from Experiences in Manila: the Role of Public-Private Collaboration and of Intermittent Therapy
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View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by edoc Strategies for Tuberculosis Control from Experiences in Manila: The Role of Public-Private Collaboration and of Intermittent Therapy INAUGURALDISSERTATION zur Erlangung der Würde eines Doktors der Philosophie vorgelegt der Philosophisch-Naturwissenschaftlichen Fakultät der Universität Basel von Christian Auer aus Bottmingen (BL) Basel, Mai 2003 Genehmigt von der Philosophisch-Naturwissenschaftlichen Fakultät der Universität Basel auf Antrag von Herrn Prof. Dr. Marcel Tanner und Herrn Professor Dr. Klaus M. Leisinger Basel, den 6. Mai 2003 Prof. Dr. Marcel Tanner Dekan DEDICATION In memory of Aling Tess and Mang Tony, former neighbours of mine, victims of tuberculosis, the unrestrained killer that terminates daily the lives of 5000 people. With the sincere hope and plea that some findings and thoughts of this dissertation will contribute to reducing tuberculosis and poverty. “The appalling global burden of tuberculosis at the turn of the millennium, despite the availability of effective control measures, is a blot on the conscience of humankind. For developing countries, the situation has become desperate and the "cursed duet" of tuberculosis and AIDS is having a devastating impact on large sections of the global community. The vital question is, can despair be turned to hope early in the next millennium?” John Grange and Almuddin Zumla, 1999 T A B L E O F C O N T E N T S Acknowledgements i Summary iii Zusammenfassung vii Abbreviations xi PART I: Introduction and overview Page Chapter 1: Background 1.1. Motivation for the thesis and overview ………………………………………………….….. 1 1.2. The burden of tuberculosis ………………………………………………………………..… 4 1.2.1. Public health indicators …………………………………………….……………….. 4 1.2.2. Economic indicators …………………………………………….…………….…….. 6 1.2.3. The burden of illness ……………………………………………….…………….….. 8 1.3. The control of tuberculosis in the world ..……………………………………………………. 10 1.3.1 DOTS - the recommended control strategy …………………………………………. 10 1.3.2. Challenges in TB control and responses to them ……………………………………. 14 1.3.3. Limitations of DOTS ………………………………………………………………… 19 1.4. Tuberculosis and its control in the Philippines ………………………………………………. 32 Chapter 2: Goal and Objectives 2.1. Overall goal ….……………………………………………………………………………..… 35 2.2. Objectives ….……………………………………………………………………………….… 35 Chapter 3: Study Areas and Data Collection Methods 3.1. Study Areas …………………………………………………………………………………… 37 3.2. Overview of Data Collection Methods ……………………………………………………….. 38 PART II: Understanding the patient: TB illness experience and help seeking Chapter 4: TB illness experience from patient, provider and community perspectives in Manila, Philippines….…………………………………………………………….. 39 Chapter 5: Health seeking and perceived causes of tuberculosis among patients in Manila, Philippines ….……………………………………………………………. 73 PART III: Strategies for improving TB control: the role of private practitioners and intermittent therapy Chapter 6: Diagnosis and management of tuberculosis by private practitioners in Manila, Philippines ….……………………………………………….…………… 91 Chapter 7: Public-private collaboration for TB control in Manila, Philippines: views from both sectors ….…………………………………………………….…. 115 Chapter 8: Feasibility, acceptability and effectiveness of fully thrice-weekly intermittent TB therapy compared to daily TB therapy in public health centres in Manila, Philippines ………………………………………………………………………… 145 PART IV: General Discussion and Conclusion Chapter 9: General Discussion and Conclusion 9.1. Key findings …………..…………………………………………………………………...… 181 9.2. Methodological considerations …………..……………………………………………….….. 182 9.3. Recommendations for public health action …………………………..….…………………... 186 9.4. Recommendations for further research …………………………..….……………………..... 189 9.5. Conclusion ………………………………………………………………………………….... 196 References………………………………………………………………………………………… 199 Annex: Patient questionnaire …………………………………………………………………… 221 Curriculum vitae…………………………………………………………………………………. 251 Acknowledgements ACKNOWLEDGEMENTS It is a privilege to have been able to carry out this research project at the Swiss Tropical Institute. I am most grateful to Prof. Dr. Marcel Tanner for the many years of stimulating and friendly inputs, support and discussions. It has been an enriching experience to carry out this PhD under the supervision of Prof. Dr. Mitchell G. Weiss. I am very grateful for his inputs and his understanding. Penelope Vounatsou deserves a big thank you for all her assistance in statistics. I am also grateful to Tom Smith and Armin Gemperle. Many thanks also go to Urs Hodel, Simon Roelly and Martin Baumann for their support in computer matters and to Daniel Anderegg for language editing. I am grateful for many colleagues here at the Swiss Tropical Institute. Christine Walliser deserves special mention for her competent care and motherly companionship. I gratefully acknowledge Dr. Armand Van Deun and his colleagues at the Mycobacteriology Unit of the Institute of Tropical Medicine in Antwerp, Belgium. It has been great that they performed (and still perform) drug susceptibility testing. Armand has been a constant source of valuable advice. Turning to Manila, I should like to first mention the College of Public Health of the University of the Philippines Manila where I studied Epidemiology and Public Health in the mid-1990’s. The studies in two chapters of this thesis have their origins at the College of Public Health. I am especially grateful to Dr. Jesus Sarol, Jr and to Dr. Ophelia Saniel. I should like to thank Drs Mariquita Mantala, Jaime Lagahid, and Vivian Lofranco of the Department of Health in Manila for agreeing to have the studies performed in Metro Manila and for their support throughout the study period. The support of Drs Dayrit, Medina and Go from the Health Office of the National Capital Region (of the Department of Health) is also acknowledged with gratitude. It has been a pleasure to get to know the TB experts of PhilCAT (Philippine Coalition Against Tuberculosis). The valuable support of Drs Rod Romulo, Camilo Roa, Charles Yu, Jimmy Montoya, and Thelma Tupasi and her colleagues at the Tropical Disease Foundation are gratefully acknowledged. I am a proud to be a member of PhilCAT! We are very grateful for the excellent collaboration with the ‘TB Research Laboratory’ of the Philippine General Hospital in Manila. The laboratory work of Mrs. Cristina Pineda, Mrs. Wilma Bulatao, and Mr. Marc Agnew Cajucom is gratefully acknowledged. i Acknowledgements Concerning Malabon, I should like to acknowledge the support of the late Dr. Soriano, the Municipal Health Officer in the late 1990’s. The co-operation and support of Dr. Garcia who then became the Acting Municipal Health Officer of Malabon is gratefully acknowledged. We are very grateful for the public health providers of Malabon for their patience with me and for their participation in the research project. Dr. Reymundo Vicente, Ms. Pacita Relos and Ms. Rhodora Alducente deserve special mention. A special thank you goes to Dr. Sonia Sia who was part of the project with the private practitioners of Malabon after the interview phase. We sincerely thank the private practitioners for allowing us to interview them and for answering our many questions. The co-operation and support of Drs Osorio and Paac, the Municipal Health Officers of Taguig is gratefully acknowledged. A big thank you goes to them and the public health providers of Taguig for accepting the study and supporting continuously. We are very grateful for all the support we received from the health centre staff. A special thank you goes to Dr. Santiago, Mrs. Francisco and Mrs. Munar. The tireless efforts of the research assistants are warmly acknowledged: Joselito Lacap, Rose Sta Ana, Melvin Sta Ana, Efren Roxas, Joshua Palma, Junior Lacuesta, Nardo Lacuesta, Angelita Ramos, Ian Bugnot, Remedios Miguel, Cyris Christy Caballero, Arnold Mariño, Emerald Lacap. Many thanks also go to Rose Pecio. I am most grateful for Lovelyn Montejo who took over the co-ordination of the study in Taguig and the data collection when it was time for me to leave Manila to go to the Swiss Tropical Institute. Her continuing efforts are deeply appreciated. I sincerely thank the TB patients of Malabon and Taguig for having received us in their homes and for having graciously answered our many questions. I deeply thank the Servants missionary community for their friendship, prayers and practical support. With thankfulness and love I think of my parents and their support. My deep gratitude goes to my wife Janice for her support and understanding about my long working hours. I thank God for life and strength and for Natalia and Jonathan, our two children given to us while this project was ongoing. The financial support of the Novartis Foundation for Sustainable Development, the Roche Research Foundation, the Rudolf Geigy Stiftung and the ‘Freiwillige Akademische Gesellschaft’ (all Basle, Switzerland) and of the Swiss Agency for Development Cooperation in Berne, is gratefully acknowledged. We are also grateful for the support of the Damien Foundation in Belgium which made the drug susceptibility testing in Antwerp possible. ii Summary SUMMARY 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