Ending TB one barangay at a time

Shobha Shukla / Bobby Ramakant *

"Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has,” had said the famous anthropologist Margaret Mead. Bearing testimony to this, a small group of people in Bantayan Municipality of Cebu, Philippines, has changed the lives of many people affected by tuberculosis (TB). TB, despite being preventable and curable, continues to be the deadliest of the infectious diseases in high TB burden countries.

Carrying innovative new diagnostic tools for TB in plastic tubs, they went from islet to islet on pump boats, braving inclement weather, to screen and diagnose people with TB. This resulted in a tremendous increase in TB case finding upfront: 316% rise in new TB case detection, and 1292% rise in screening of those with presumptive TB.

Imagine the difference it can make in the Philippines' fight to end TB if such interventions can be scaled up and become a norm.

As per the latest Global TB Report 2022 of the World Health Organization (WHO), out of the estimated 741,000 people with TB in the Philippines, only 321,600 were notified to the national programme, and over 60,000 lives were lost due to TB.

As of now, only 43 out of every 100 people with TB are reached by the TB services in the Philippines, and only 65% of those reached, get a WHO recommended molecular test diagnosis, while the rest get a smear microscopy (which underperforms in TB diagnosis), or get treated without any bacteriological confirmation.

As early and accurate TB diagnosis is the gateway to TB care pathway (and breaking the chain of infection transmission), the Philippines has a two-fold task:
- firstly, it must ensure that it is reaching out to all those with TB (and not just 43/100), and
- secondly, it must use WHO recommended molecular tests to diagnose TB timely and correctly. This paradigm shift in TB diagnostics is a critical entry point, not only to the full spectrum of TB care cascade, but also towards ending TB in the country.

Ending TB – one barangay at a time with x-ray and Truenat

When the WHO recommended point-of-care, decentralised, laboratory independent and battery operated molecular test Truenat (made by Molbio Diagnostics), along with the ultra-portable and battery operated x-ray made by Fujifilm, was deployed in Bantayan islets, new TB case notifications, as well as treatment success rate, increased manifold, confirmed Dr Samantha Tinsay, Municipal Health Officer, Bantayan Municipality, Cebu, Philippines. "TB is a disease of poverty. Unfortunately here in our island of Bantayan a lot of people have TB because of malnutrition and poor hygiene," she said. Malnutrition is the biggest risk factor for TB.

Using latest and state-of-the-art diagnostic tools in the Philippines was made possible in 2022 by introducing New Tools Project (iNTP) of the Stop TB Partnership and United States Agency for International Development (USAID), which has helped in the rollout of a package of latest innovations in diagnostics, treatments, and digital health technologies to strengthen TB care in high burden countries.

Bantayan is the largest municipality of Bantayan island and it has 25 barangays (small townships) and one district hospital which is understaffed and undersupplied. These areas are also marked as geographically isolated and disadvantaged areas (GIDA). Most of the people here are fisherfolk or farmers and their income is Pesos 300-350 (USD 6-7) a day.

“During September to October 2022, we were able to screen 1774 people with presumptive TB by bringing these tools right to their doorstep. Most of them cannot afford to travel to the mainland for diagnosis or treatment. So we brought TB point-of-care testing to their doorsteps and saw a very high increase in case detection as well as in treatment success rate,” said Dr Tinsay. "As TB diagnostic technology was brought to the people (and not the other way round), people were more open to getting tested for TB."

“When the going gets tough, the tough gets going”

When Dr Samantha Tinsay began the introduction of these new innovative diagnostic tools in September 2022, extreme climate events- such as typhoons and storms- compounded the challenge. But it was sheer determination on her and her team’s part to hop on a pump boat and brave the storms and typhoons to go from islet to islet and find TB, and treat TB.

"When we started this project in September 2022, it was the middle of the typhoon season. So one of the challenges we often faced was the bad weather conditions. It took a lot of teamwork and effort with my staff and the barangay healthcare workers and officials of the local health unit - It was an all-in-one effort supported by the community,” shared Dr Tinsay.

The x-ray and Truenat molecular test were brought to the Bantayan Rural Health Unit, and packed in a suitcase with wheels for transportation. Both of these machines fitted well in a moulded plastic tub, and were transported via pump boats.

On 29 October 2022, Tropical Storm Nalgae, locally known as Paeng, hit the Philippines, and affected around 4.8 million people within a week. On that fateful day, Dr Samantha Tinsay and her team were en route to one of the islets with the diagnostics tools in tow. “We did not know that a storm signal had been raised, and that nobody should be travelling or working as we were out of the range of mobile signal. Nevertheless, rain or sunshine, we were working and could not have stopped as patients were already waiting at the clinic,” said the spirited Dr Tinsay.

Making a difference

Because of the introduction of new tools, TB case detection went up from 110 in 2021, to 458 in 2022 (an increase of >316%). The number of people who got tested for TB also went up from 180 people in 2021, to 2506 people in 2022 (an astronomical increase of 1292%).

“TB treatment success rate has also increased to 97% in 2023,”she confirmed. Average TB treatment success rate in the Philippines was 76% in 2021 as per the WHO report.

“These new innovative TB diagnostic tools are very crucial in the fight against TB, especially for people living in geographically isolated and disadvantaged areas (GIDA). These tools can really help eradicate TB. Bringing these tools to the people in a country like the Philippines where TB is very rampant, will help end TB, one Barangay at a time,” rightly said Dr Tinsay.

TB diagnosis before the new tools were introduced in Bantayan

“I started working in Bantayan in November 2021. Prior to that the method of screening for TB was inefficient and also expensive for the people. We had the Gene Xpert machine for molecular testing. But getting the x-ray done was a challenge for the patients as they did not want to pay Pesos 350- 450 extra for the x-ray. It was more than their income for one day. In 2022, (before the Truenat molecular test or portable x-ray came), we started a partnership with an NGO called the Philippine Business for Social Progress. They provided free chest x-ray vouchers, which was very helpful.

But the hurdle was that the people did not want to pay the boat fare to go to the x-ray labs. Now we have more partners, including Christian organisations, who are willing to donate mobile x-rays with trucks that have x-ray machines in them. But the challenge in using them is that you cannot bring the trucks to the islets. They are situated in the mainland, which is good, but not as good as the Truenat and ultraportable x-ray. They are the real point-of-care screening and confirmatory tests for TB that we can do right at the doorstep of people and can schedule it anywhere anytime!” said Dr Tinsay.

Flowchart for TB screening and testing

The barangay health workers checked the vital signs of the persons, the community nurses took the persons’ medical history and did their registration. Then, the radiology technicians took the chest x-ray. “If the chest x-ray was positive, then molecular testing of sputum was done by the medical technologist, using Truenat molecular test machine, and they were accordingly referred to doctors to begin medical treatment on the spot, as well as for provider initiated counselling and testing for HIV. We also did HIV testing on the spot on the same day, as we know that a lot persons with HIV are also co-infected with TB. We wanted to end the stigma and the frustration of the patient by offering the tests on the spot,” she added.

Artificial intelligence

The portable x-ray uses artificial intelligence to read TB and shows a red spot if there is TB.

Recounting her experience of intensified TB case finding, Dr Tinsay shared that “On 6th of September 2022, our first stop was at Sayao in Bantigue barangay, which has one of the highest cases of TB in this barangay. Here we tested 117 patients out of which 7 were confirmed positive for TB, a case detection rate of 6%. All this was done on the same day. We started at 8am and finished at ~5pm. This was more than any diagnostic centre will ever test and start treatment for TB in one day.”

The Fujfilm ultraportable x-ray and Truenat molecular testing machine do not require laboratory infrastructure. “We were out in an open field and the barangay officials had just put up tents. We used a shower curtain as a makeshift screen for x-ray. It was like setting up a photo booth anywhere for the ultraportable x-ray,” she said.

On 16 September 2022, her team recorded the highest TB case finding rate of 14.4% in Kabac. Narrating her experience of travelling to Hilotongan where travel is difficult due to low tide, her team began at 6am in the morning to reach there on time. TB case notification rate was 12.3%. They used a local church facility to set up the x-ray and molecular testing equipment.

Her hardest travel was to Luyongbaybay on 30th September 2022 for which she and her team had to leave at 3am when it was high tide (if it is low tide then they cannot cross the sea as the boat gets stuck). TB screening and testing was done right outside the day-care centre and inside a gym. “I was the only doctor there and I checked 238 patients from 6am until 4 pm. We also provided free blood sugar testing and some paediatric check-ups,” she said. “This was the maximum number of patients we checked in one day, thanks once again to the teamwork and very supportive barangay officials. Before we arrived, there was a thunderstorm, so we were soaking wet (drenched) when we reached this Barangay. We were not carrying any change of clothes with us. Once again, the barangay officials and the people of the islet were very supportive (and gave us free t-shirts to wear).”

“On an average we were testing 70 to 120 patients in a day, using these new tools. Every barangay that we went to, there was at least one positive case of TB. Nowhere was there zero case detection,” she told.

The future ahead

In Bantayan island there are 3 different municipalities. Bantayan is the largest, and the other two are Santa Fe and Madridejos. “If we get the innovative New Tools Project back, we are willing to share the case findings with the other two municipalities, just as we did last year,” said Dr Tinsay.

“Just two days ago we had a patient living with HIV, who also had TB, who passed away at the age of 24 years. This should not happen anymore. A lot of people do not seek help because of the TB stigma, and because the diagnostic tools are at such far flung places and out of reach for them. By bringing point-of-care testing at their doorstep, we can help end TB- one barangay at a time,” she summed up.