Written by Jenny Lei Ravelo / Devex

Upon entering the Delpan quarantine facility for COVID-19 patients in Manila, a blue tarpaulin greets visitors scheduled for coronavirus swab testing with a question: “Kumusta Baga?,” which translates to “How are your lungs?” Below, in bolded letters, it reads: “FREE CHEST X-RAY.”

The message targets individuals scheduled to get a COVID-19 swab test in the facility. It is also part of the latest efforts to actively find tuberculosis cases amid the pandemic, which has killed over 35,000 people as of Sept. 14 — the second-highest death toll in Southeast Asia after Indonesia.

Since COVID-19 hit the country, many Filipinos have avoided health facilities unless in need of immediate medical attention, said Dr. Maria Julieta Recidoro, officer in charge at Manila Health Department’s division of TB prevention and control.

Most health workers have also been redirected to the country’s COVID-19 response, leaving limited resources for other health programs. Consequently, the detection of TB cases has suffered: In 2020, notifications for new and relapse TB cases went down by 38%, according to the “Philippines National Tuberculosis Report 2021.”

In Manila, the number of registered TB cases, including those with drug-resistant TB, fell by over 60%, from 14,141 cases in 2019 to 5,463 in 2020, Recidoro told Devex.

“So our strategy is to really push, as much as we can, for active TB case finding,” she said in mixed Filipino and English.

Finding opportunity in the crisis

In September 2020, the Department of Health, published the National TB Control Program Adaptive Plan, which calls for the continued provision of TB services, including screening for TB, and details safety measures for health care providers.

During the second half of 2020, as Manila launched a COVID-19 testing initiative among market vendors, the city’s TB control team spotted an opportunity to find new cases: They set up TB screening and sputum collection in markets, in partnership with market administration officials and market vendor associations.

This effort helped them to not only screen and identify TB patients, but also to tap into these local market offices as partners. Now, patients can now conveniently get their medicines in these offices instead of going to health centers. 

Setting up a mobile chest X-ray van at the Delpan quarantine facility is also part of their latest efforts to screen for TB by piggybacking on the pandemic response. It is funded by the U.S. Agency for International Development under the TB Innovations and Health Systems Strengthening Project managed by FHI 360, with on-the-ground support from Innovations for Community Health.

The result of a chest X-ray is made available within minutes, allowing health workers to determine whether to recommend individuals to get confirmatory testing for TB by submitting a sputum sample. 

Symptomatic individuals such as those with cough or fever and those with abnormal chest X-ray results are recommended to submit sputum samples, which are then tested for TB. Results are sent electronically, and for confirmed TB cases the local government initiates treatment.

[Some municipalities' concern is] if we are able to find TB cases during these active case finding activities: What will they do if they don't have supply of medicine.

— Alberto Ong Jr., TB program project lead, Culion Foundation

On the team’s first day on Sept. 2, it was able to screen 45 individuals, including 10 who submitted sputum samples for confirmatory TB testing. In one week, they were able to screen and test a total of 217 individuals, according to April Joy Cagas, field implementation officer at FHI 360’s TB screening and testing activity at the Delpan quarantine facility.

In other locations, some NGOs are also partnering with local government units to do TB screening in COVID-19 vaccination sites — though not in Manila, where there were concerns about being able to accommodate everyone for screenings and needing to allay the potential frustration of those who cannot avail of the free chest X-rays, Recidoro said.

The great disruptor

Through partnerships, Recidoro hopes the number of TB patients they find would pick up this year — even if only an additional 20%, to top last year’s results. As of Sept. 8, Manila City has registered 5,564 TB cases for 2021 — 1.8% more than last year’s total.

COVID-19 can be overwhelming due to the sheer number of infections people see on a daily basis. But she said that doesn’t mean TB should be neglected. 

“We have to do all we can, exert all our efforts, be very, very aggressive … in finding our missed [TB] cases, and scale-up TB preventive treatment to be able to save lives,” she said.

For infection prevention and control, individuals with symptoms are not recommended for chest X-ray, but are instead asked to submit a sputum sample for TB diagnosis.

Over 100,000 Filipinos may die of TB in the next five years if disruptions in TB services continue, the DOH estimated in March.

Recidoro said much of the focus this year remains on COVID-19 vaccinations, and most health center staff have been asked to help in the effort.

“Ïf last year we still have some staff available to attend to patients who come to health centers, this year we almost have none,” she said.

In other parts of the country, an increase in COVID-19 cases and pandemic restrictions also continue to challenge efforts in finding TB patients.

Culion Foundation, a local NGO doing active TB case finding in southern Luzon provinces, was not able to carry out active TB case finding activities in some island provinces because of a recent spike in COVID-19 cases.

But they are finding ways to navigate the situation. In May, when border restrictions meant they were unable to be physically present for active case finding on the island of Araceli, in the province of Palawan, the NGO sent local X-ray providers in the area and engaged with local health worker volunteers to look for TB cases, said Dr. Alberto Ong Jr., the foundation’s project lead for its TB program.

“They [have been] requesting it for almost a year already, and this is the first time that an X-ray machine was able to reach that island,” he told Devex.

Other long-standing challenges remain on top of COVID-19. Some municipalities have expressed concerns about limited medicine supplies, Ong said.

“Some municipalities are hesitant actually to conduct active case finding in their areas because their concern is ... if we are able to find TB cases during these active case finding activities: What will they do if they don't have supply of medicine,” he said.