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Storytelling the Enhanced Hospital TB-DOTS experience

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Storytelling the Hospital TB-DOTS Experience

Writers: Bernadette V. Neri Sharon Anne Briones PangilinanEditors: Bernadette V. Neri Sharon Anne Briones Pangilinan Dr. Mariquita Mantala Dr. Ma. Lorela Averilla

Cover and Layout Design: Jennifer T. PadillaPhotos: Jennifer T. Padilla

2013Printed by:

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INTRODUCTION

Telling “success stories” usually prick everyone’s attention and interest. Unlike statistics or numbers, they are easily visualized, they evoke good feelings and they generate a desire to undergo the same experience and get the same results. Thus, when the question of how do we share the CATCH TB cases project achievements to a wider audience, we decided to do it through personal sharing or storytelling.

CATCH TB cases project stands for Collaboration for Additional TB Cases through Contacts and Hospitals against TB. It was a three year, collaborative project on TB control by the Department of Health, the World Health Organization and the Canadian International Development Agency.

In 2009, the National TB Control Program (NTP) was grappling with the “missing TB cases” - those who were not notified to the program. At that time, 160,000 cases were reflected in the NTP report - almost 100,000 short of the estimated total TB cases. This is an unpleasant reality despite the free TB diagnostic and treatment services being provided by thousands of health centers all over the country. Evidences were gathered and reviewed and, eureka!!! A national survey revealed that four out of ten patients with signs and symptoms of TB went to the hospitals – more than those who consulted the health centers. Understandably, since hospitals have the experts, a wide array of diagnostic tests and are open 24 hours a day. Thus, the CATCH project assisted 17 big public hospitals in Metro Manila to improve its TB services. In 3 years, these hospitals found, treated and successfully referred 15,000 TB cases. All were reported to NTP.

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The selected ten stories featured here will give the reader a snap shot of the thousands of stories that took place in the 17 hospitals in the past three years. They came from various perspectives – TB patients who got treated, health care providers who learned and felt appreciated, hospital head who felt proud of what they did, and the program managers who discovered an approach in finding many of the “missing TB cases”. We thank them for sharing their stories.

We urge our readers to read the stories carefully, imagine the journey they undertook and understand the results. But at the end we encourage you to act. It may be simply advising your neighbor to consult the hospital TB-DOTS clinics, asking why your hospital is not doing the same thing, instructing your staff to adopt this approach or contacting the Department of Health or hospitals for more information and offer support.

These stories are for all of us who dream of a TB-free Philippines where each can maximize one’s potential without the burden of illness and where we can equitably enjoy the fruits of a productive nation.

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TABLE OF CONTENTS

Basta TB, DOTS the way to go! 6Rosalind G. Vianzon, MD, MPHNTP ManagerDepartment of Health (DOH)

Upholding Accessible TB Treatent for the Masses 10Victor J. Dela Cruz, MD, CESO IVMedical Center Chief II Tondo Medical Center (TMC)

UP PRIME TB-DOTS: A PGH Legacy 14 Regina P. Berba MD, MSc., FPCP, FPSMIDClinical Associate Professor, UP PGH Coordinator for Internal Networking, UP PRIME TB Program Team

Diagnosis and Treatment: A Delicate Balance 18Daphne D. Bate, MD, FPCP, FPCCP, MsPHTB Team HeadQuezon City General Hospital (QCGH)

Pioneering Health 22Margery R. Genabe, MDSan Joaquin Health Center Physician, andNTP Medical CoordinatorPasig City

Birthing a Child Twice 26Mommy Arlene Ganacial and daughter Fhoebe Ganancial Student

Leaving No Stones Unturned 30Melinda C. Santiago, RNTB Clinic NurseJose R. Reyes Memorial Medical Center (JRRMMC)

Continuous Care 34Ian ArselonWorker

TB-DOTS as a Viable Social Capital Investment 36 Evelyn F. Camarador, RN, MANNurse SupervisorHEPO DesignateNTP Nurse CoordinatorAmang Rodriguez Memorial Medical Center (ARMMC)

Surpassing Tuberculosis 40 Salvacion DomoStore owner

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Basta TB, DOTS the way to go!Rosalind G. Vianzon, MD, MPHNTP ManagerDepartment of Health (DOH)

It has been more than 20 years of government service for Dr. Rosalind Vianzon but the burning desire for the betterment of peoples’ physical wellness and the passion for community health stay because of her love for public health. In this field, she explained, medical practice is not just confined within its clinical aspect. There are administrative and management tasks, too. Public health doctors do not only manage the health of an individual, they manage the well-being of the whole community.

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That principle guides Dr. Vianzon in her responsibilities as the current National TB ControlProgram (NTP) Manager especially in implementing TB-DOTS, which is a strategy employed by the NTP to treat and control tuberculosis in the country.

The primary role of NTP is to develop policies, standards, and guidelines on how to betterdeliver TB-DOTS services to the public. They also do partnerships with the private sector, both local and international. Dr. Vianzon stated that these stratagems work as proven by NTP outputs through the years.

Efforts to control tuberculosis in the Philippines already started since 1910 through the initiative of nongovernmental organization Philippine TB Society, Inc. (PTSI). The government started to assist the PTSI and eventually took over the management of the whole program almost a decade after. Since then, the TB situation in the country has improved. In 1986, the NTP was enhanced to further strengthen the battle against the disease.

“Statistics will show the effectiveness of the TB-DOTS program. Hindi na nakakatakot ang TB ngayon dahil nagagamot na siya. (Tuberculosis is not to be feared

Basta TB, DOTS the way to go!

anymore because it is curable.),” Dr. Vianzon proudly stated. “More than 90% of the patients recover from TB after undergoing the six-month medication plan. This is a major leap as compared to the old treatment when a patient used to take various drugs for months if not years yet with limited recovery.”

She also stressed that tuberculosis is a disease affecting the economic age group. Today, a TB patient can still work and be productive because there is cure. This is very important because once the disease is controlled, it can have a positive impact on the economic growth of the country.

Department of Health (DOH)

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The NTP Manager emphasized that hospitals are significant components in the project. According to her, whether private or public, 42% of TB suspects went to hospitals

because they provide 24-hour service as compared to health centers that work on an outpatient basis only. Encouraging hospitals to adopt TB-DOTS widens the number of patients that can be treated. CATCH TB Cases Project, a WHO/CIDA intiative, and Secure TB, a PTSI/TBLINC/USAID project, have demonstrated that hospital TB-DOTS is effective and feasible.

According to Dr. Vianzon, this campaign is moving strong in Metro Manila public hospitals. Some private clinic and hospitals are starting to get involved due to the program’s success and positive results. For NTP, the challenge now is how to engage more private hospitals.

Adopting TB-DOTS both in the public and private hospital setting can also help control difficult situations

such as the development of multi-drug resistant tuberculosis. As explained by Dr. Vianzon, “If every hospital is linked to the program, there will be unity in the process of medicating patients. Kung iisa lang ang galaw ng public at private, iisa lang ang ii-implement na policy. Maiiwasan ang problema ng multi-drug resistant bacteria. (If both public and private hospitals employ the same methods in treating TB, problems of multi-drug resistant bacteria could be prevented.)”

Dr. Vianzon also said that TB-DOTS could help in boosting the stature of the hospital because it is designed to treat large numbers of TB patients. It will also help in their training mechanism, particularly in TB medication, because they are implementing a program that is nationally accepted.

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She explained that to encourage more TB patients to undergo treatment, the whole TB-DOTS program is designed to be for free. Private hospitals need not worry about this because the NTP will provide the drugs and laboratory services needed. The hospitals’ task is only to put up a space and designate a person to focus on quality TB-DOTS implementation.

When asked why she stayed in the program, Dr. Vianzon confidently smiled and said, “It is rewarding and professionally fulfilling. There are clear outputs in whatever you do. With the directions and standards implemented, you see how these really contribute to the society. And it makes you think and hope that it can be done and the whole country could benefit from it. Kayang-kaya naman pala. We just need to implement the program and show results.”

ANTI-TB DRUGS

LABORATORY SUPPLIES & MICROSCOPE

SUPPORT FOR TRAININGS AND ORIENTATIONS

RECORDING AND REPORTING TOOLS

THE NTP PROVIDES THE FOLLOWING TO ENHANCED HOSPITAL TB-DOTS IMPLEMENTERS

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Upholding Accessible TB Treatment for the Masses

Tondo is not only home to Bonifacio and thousands of other brave Filipinos who fought against colonial oppression. It is also home to the dedicated health workers of the Tondo Medical Center who are ready to protect the urban poor community against life threatening diseases like tuberculosis.

Victor J. Dela Cruz, MD, CESO IV Medical Center Chief IITondo Medical Center (TMC)

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Tondo Medical Center (TMC)

TMC has started its crusade against TB since the 1990s, even before the introduction of the CATCH TB cases project of the Department of Health and the World Health Organization. But it was only in 2010 that the hospital was able to institutionalize the TB-DOTS program and set-up their own TB clinic. This new strategy to eliminate TB didn’t start without resistance among its workforce as it introduces a new treatment protocol different from the one they are already acquainted with. According to Medical Center Chief Dr. Victor de la Cruz, the TMC management conducted a series of orientation among its health care providers including their administrative staff to let them

understand and appreciate the TB DOTS program. It took them half a year before they were able to overcome the challenges that confronted the program.

He added, “As we go along and with the effort exerted by the DOH, nagkaroon ng cooperation & understanding. Ngayon, tanggap na at ine-endorse na ng mga specialty societies ang TB DOTS as far as right treatment for diagnosis and treatment of the disease is concerned. Nagkaroon na ng levelling of minds.” (As we go along and with the effort exerted by the DOH, we were able to establish cooperation and understanding. Specialty societies are now endorsing TB DOTS as far as right treatment for controlling and treatment of the disease is concerned. We were able to achieve a levelling of minds.”)

Victor J. Dela Cruz, MD, CESO IV Medical Center Chief IITondo Medical Center (TMC)

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When asked about the advantages of introducing TB DOTS in a public hospital like TMC, he said, “We have become more effective in treating TB patients here in our hospital. We are also successful partners in referring patients to the LGU. Since we cannot accomodate all the TB patients who visit our hospital for medical care, what we do is refer them to the nearest local health center accessible to them.”

The Medical Center Chief emphasised the importance of setting up TB DOTS clinic in both private and public hospitals. Dr. de la Cruz said that it gives credibility and recognition to the services that the institution offers. “If the local health centers have put up their own TB DOTS clinic, all the more that the big hospital institutions like

Dr. de la Cruz declared that the TMC is primed to play an active role in attaining the Millenium Development Goal # 6 -- the control of TB, HIV/AIDS and other diseases in the Philippines.

This advocacy to control TB fulfills the TMC’s goal which is to “sustain disease prevention activities” and “provide health care to as many residents of Tondo and nearby areas.” In fact, TB is among the top 10 dis-eases listed in their catchment area. “This shows that it remains a serious concern,” said Dr. de la Cruz. Despite the flourishing business district in Tondo, majority of its residents still belong to the unemployed, under-employed and the working class sector with salaries below minimum wage. This condition makes them the most vulnerable group to killer ailments like TB.

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TMC should adopt it. If private and government hospitals will work together in the implementation of the TB DOTS program, we will surely triumph in our task to eradicate TB here in our country.”

TMC is a top-notcher in the CATCH TB program. Dr. de la Cruz shares the two important components that contribute to their success in implementing the program. Number one is the enduring dedication of their hospital staff, particularly Dr. Myrna Rivera and nurse Cathy Fellores. Dr. Myrna has been part of the TMC’s advocacy since day one. Second is the hospital management’s eager support to the program. “Medyo mahihirapan kami kapag wala ang dalawang component na iyon. Kasama sa support ng management ang budget, manpower, facilities. Kapag hindi mo ito minahal at inalagaan, talagang hindi ito magpro-progress.” (We will have a difficult time implementing the program without these two components. Part of the management’s support is providing manpower, budget and facilities. The program will surely not succeed if we will not learn how to love and take care of it.”

Their biggest challenge at the moment is the sustainability of the program. The TMC’s solution to this is through establishing partnership with the LGU. The TMC has also organized CATCH-TB Projects orientation for both the LGU and health centers in the Tondo community.

“We are a good partner of the LGU. Our success is also the LGU’s success,” said Dr. de la Cruz.

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UP PRIME TB-DOTS: A PGH Legacy

Just as treating tuberculosis is an ongoing endeavor, so too are the efforts in enhancing the current medications especially for complicated TB cases. The Philippine General Hospital (PGH) is one of the health institutions that focuses on this. Its commitment to the well-being of the people drove it to initiate the formation of PRIME (PGH Responsive Integrated Multidisciplinary Enhanced) TB-DOTS, which aims not only to address the increasing number of patients with severe types of tuberculosis but also to provide the public an improved TB diagnosis, treatment, and prevention strategies.Regina P. Berba MD, MSc., FPCP, FPSMID

Clinical Associate Professor, UP-PGH Coordinator for Internal Networking, UP PRIME TB Program Team

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Contrary to the expectations of the medical community, TB-DOTS was not immediately adopted in PGH during its launch in the Philippines in the 1990s. Despite the fact that most of the important people in TB research in the country are PGH professors, the TB-DOTS project was only set up in the hospital in 2010. Head of PGH Internal Networking Department and TB-DOTS physician Dr. Regina P. Berba explained that one of the factors that played a part on this was the complexity of being the largest government hospital administered by a state university.

“Being a university hospital, PGH focuses on tertiary care illnesses. Most people think that TB is mainly for primary care centers. It was difficult to convince them

that tuberculosis is actually a health priority,” Dr. Berba said. “But as years go by, the set of patients with grave and complicated types of tuberculosis who go to PGH spoke for the need to establish the TB-DOTS program.”

According to Dr. Berba, most of their patients have other medical problems on top of their TB like diabetes, chronic lung disease, HIV, and others. If it is just really tuberculosis, they tend to be multi-drug resistant (MDRTB) or extra-pulmonary (EPTB) like TB meningitis, TB of the scrotum, TB of the liver, and TB of the pericardium. Cases like these need specific treatment and medicine, and can only be addressed by means of a multi-disciplinary approach particular to the kind of TB the patient has. Thus, the concept of PRIME TB-DOTS emerged.

Putting up the TB-DOTS center is another challenge faced by the PGH. The hospital’s land area is already fully occupied. They had no choice but

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medication process of TB-DOTS, particularly the follow-up and monitoring of cases because patients live outside of Metro Manila. Although PGH refers them to the nearest health center in their community, keeping track of their progress or non-progress really poses a big challenge.

Dr. Berba hopes to involve students in the program particularly in the one-on-one orientation with the patient’s family. “The students will be of great help because they have sufficient time to fully discuss the procedure,” Dr. Berba explained. This is very important because family members also play as treatment partners of the patients.

to partly convert a small library into a clinic space. The CATCH TB Cases Project, a WHO/CIDA Initiative provided the money that was used in the renovation and technical support while the National TB Control Program (NTP) donated medicines, microscope and some reporting and recording tools.

The core team handling the program is composed of three doctors (including Dr. Berba), a nurse, and fellows from the different

departments such as the department of infectious diseases, pulmonary medicine, and pediatric diseases. Even though there is no additional compensation, they tender their expertise and time in the service of the people. But their dedication to the profession is not enough to parallel the number of patients who go to PGH. Known as the hospital for the poor, patients with serious medical conditions from all over the country go here for treatment. This fact complicates the

Dr. Berba shows the green and yellow forms

used in the referral systemA World TB Day Celebration at PGH

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“Engaging students is not just to make up for the limited work force in the clinic,” said Dr. Berba. “As future medical practitioners, the knowledge and experience will benefit them. They could carry on the skill and practice (of managing TB correctly) after graduation.” Dr. Berba could personally vouch for this because she, too, was once a student of the UP College of Medicine. Her trainings greatly influenced her decision to stay in the country and help her fellow Filipinos instead of migrating overseas.

Discovery and development of medicine and treatment is rooted in health research. As stated by Dr. Berba, the whole program is advantageous to the academic community of PGH. “Our current registry is really a very rich source of additional research materials. By integrating PRIME TB-DOTS into the main programs of the hospital, we will be serving not only our PGH community but the whole national

program as well,” she proudly exclaimed. “In fact, PGH has verbally communicated its intention to expand and become the Center for Complicated TB.”

In connection to this, Dr. Berba also hopes that more hospitals, if not all, would engage in the project as well. “The concept of this national program is very good. For it to be successful, hospitals have to recognize that significant proportion of patients go to them than in health centers. Kung hindi mae-engage ang hospitals as TB-DOTS centers, mawawala ang significant proportion of patients even if health centers in the local government are doing well,” she said.

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Treatment begins with proper diagnosis. It provides an insight into the disease. Physicians could only plan a medication program once the condition is appropriately identified. TB Team Head Dr. Daphne Bate knows and applies this by heart because it is the duty of her team to ensure that each tuberculosis patient of the Quezon City General Hospital (QCGH) has been subjected to proper screening and evaluation before being endorsed to undergo treatment.

Diagnosis and Treatment: A Delicate Balance

Daphne D. Bate, MD, FPCP, FPCCP, MsPHTB Team HeadQuezon City General Hospital (QCGH)

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Dr. Bate has been working with TB-DOTS since its launch in Quezon City in 1998. She was the training officer of the QCGH. But when the hospital got involved in the CATCH TB Project in 2010, she was designated to become the TB Team head. “It is a difficult job that I learned to love and enjoy because it helped me expand my field of expertise. I even developed competency in reading X-rays because of the program,” she said.

Dr. Bate’s position as Head of the QCGH Department of Internal Medicine is vital in engaging other resident physicians, even those who specialize outside

Pulmonary Medicine, become experts in diagnosing tuberculosis. TB cases make good learning materials for physicians, she said. Enjoining doctors from various fields broadens the pool of hospital resource team, and the detection of tuberculosis is no longer limited in the pulmonary division. The diagnostic committee in QCGH, for example, has ten doctors from Family Medicine, three from Internal Medicine, and two from the Pediatric Medicine. All of them are now authorities in TB management.

TB-DOTS training also prevents cases of misdiagnosis, which may lead to inappropriate treatment that will result to multi-drug resistant tuberculosis. “We

Quezon City General Hospital (New Building)

Up for renovation, the old QCMC building

shall soon house a bigger TB-DOTS clinic

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do not want this kind of TB because it is harder to cure, it requires expensive drugs, and it takes longer medication,” Bate said.

The DOH National TB Program (NTP) in collaboration with the World Health Organisation (WHO) and Canadian International Development Agency (CIDA) put up the CATCH TB Cases Project in 2010. The purpose was to detect missing TB cases or those diagnosed at the hospitals but not reported to the NTP. The main strategy was to strengthen the internal TB referral systems and ensure that TB patients are properly referred to TB-DOTS facilities - mostly health centers in Quezon City. Dr. Rochelle Paulino and Ms. Felisa Tang, the NTP Team of Quezon City Health Office, recognized the contribution of QCGH in TB control efforts of the city.

According to Dr. Bate, doctors should tell their patients the impact of the disease to our country’s development and the Filipino families’ health because awareness will drive them to be responsible in complying with the medication process. It should be stressed that not pushing through with the six-month treatment would cause the bacteria to mutate into new forms that are immune to the current drugs for TB.

The TB-DOTS experience in QCGH revealed another facet of the challenge in catching TB patients. They realized that more patients go to hospitals compared to health centers because they do not want their

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community to identify them with the illness. Dr. Bate emphasized the significance of more hospitals to work with the NTP. She alone sees about 30 to 50 referrals in a week, and almost all of them finish the treatment. If all hospitals adopt TB-DOTS guidelines and tools, more patients will be treated.

“Hindi na dapat nagkaka-TB sa Pilipinas kung marami ang magbibigay ng TB-DOTS. (Tuberculosis wouldn’t be a problem in the Philippines if clinics and hospitals will implement TB-DOTS.),” Dr. Bate confidently said. Metro Manila has 230 hospitals and most are in Quezon City, thus engaging them would result to a very big impact in case finding and case holding.

Training the QCGH hospital staff to ensure the proper implementation of TB-DOTS protocol

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The path towards a certain goal is never easy. Dr. Margery Genabe, Pasig City National Tuberculosis Program (NTP) coordinator for 13 years, attested to this. Together with her team, comprised of a NTP nurse and medical technologist, they oversee the implementations of the TB control program in the whole Pasig area.

Margery R. Genabe, MDSan Joaquin Health Center Physician, and

NTP Medical CoordinatorPasig City

Pioneering Health

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It is their responsibility to ensure that there are adequate logistical support for all the DOTS facilities in the City, the NTP policies are properly implemented, and necessary reports are submitted on time. They are also responsible for providing assistance to hospitals implementing DOTS like Rizal Medical Center (RMC).

In 2010, the RMC was engaged by the NTP to pilot the CATCH TB cases project supported by WHO-CIDA. One of the core goals of the project is to ensure that all TB patients who consulted in hospitals is referred to the hospital TB clinic, or referred to health centers for treatment. The project developed a referral slip to ensure that TB patients are accepted and registered at

Pioneering Health

the health centers. It was also under this project that the Pasig City NTP core team was able to organize a hospital-health center dialogue. This enabled them to orient health center staff about the hospital TB-DOTS process and guarantee the success of patient referrals from RMC.

Aside from the technical support Dr. Genabe provides to the RMC TB team, she likewise heads the San Joaquin Health Center (SJHC) in Pasig City, which was one of the five health providers that initially adopted the TB-DOTS program under the CRUSH TB PROJECT in 1997. Since then, the SJHC contributed significant

Rizal Medical Center (RMC)

San Joaquin Health Center

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accomplishments being the first community-based TB-DOTS health center.

Through their dedication to curb the TB epidemic, efforts were made to further scale-up their TB control program. By 2007, they have successfully engaged two private hospitals as part of the public-private mix DOTS (PPMD) initiative -- these are the St. Camillus Hospital and The Medical City. In addition to this, employers in the city acknowledge the reliability of the treatment provided by TB-DOTS made possible by the comprehensive unified policy among government agencies as well as private companies. In fact, a

commercial bank in Ortigas now avails of these services. Dr. Genabe sees this as recognition of the quality services being provided to their constituents.

Upon seeing the contribution and importance of the hospital TB DOTS in Rizal Medical Center, Dr. Genabe initiated the inclusion of their very own LGU hospital- the Pasig City General Hospital (PCGH) to the project. In mid-2012, PCGH started implementing hospital TB-DOTS. Like other hospitals, the Pasig City Health Office, through the NTP, provides anti-TB drugs and laboratory supplies to the hospital. Quarterly external quality assessment (EQA) for sputum smear

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microscopy is also being done in these hospitals. Regular trainings and orientation of hospital staff are also being conducted together with Dr. Genabe and her team. Dr.Genabe is also part of the TBDC of PCGH that meets twice a month to deliberate on some TB cases referred by the health centers.

Towards the end of December 2012, more than 900 TB patients from RMC and PCGH have benefited from the collaboration of the hospitals and Pasig City Health Center in TB control.

Being a TB medical coordinator is a daunting task, much more if one is also managing a health center. But this does not diminish the spirit of Dr. Genabe and her team. They are currently active in engaging other hospitals in the city to implement hospital TB DOTS. Dr. Genabe hopes that through their collaborative efforts, all TB patients seen by hospitals in Pasig City are given the proper care they deserve. For them, this is an important step in achieving a TB-free community.

Pasig City General Hospital (PCGH)

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Birthing a Child TwiceThe agony of losing a loved one is immeasurable, so no one dares to accommodate even the slightest thought of it. To be faced with the possibility of that situation unprepared, one would realize that the state of almost losing someone is as difficult to get through as the actual loss. Mommy Arlene went through an ordeal when her nine-year-old daughter, Fhoebe Shane, nearly died because of TB Meningitis.

Mommy Arlene Ganacial and daughter Fhoebe Ganancial Student

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It was the latter part of June 2012 when Fhoebe started to have headaches and fever. Arlene gave her paracetamol thinking it was just the usual sickness that children get due to unexpected weather changes. The medicine did not help. Instead, Fhoebe complained of worsening pain. Arlene and her husband took Fhoebe to the nearest private clinic. Unfortunately, the clinic was unable to diagnose the cause of Fhoebe’s headaches, which then turned into sei-zures. As if things could not get worse, the child suddenly lost her ability to stand and walk. A few days after, and to Arlene’s distress, Fhoebe failed to wake up.

Fhoebe before and after her TB-DOTS treatment

Mommy Arlene Ganacial and daughter Fhoebe Ganancial Student

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With the help of Nurse Ana and the rest of the TB-DOTS staff at the National Children’s Hospital, every visit to the clinic was a step further to Fhoebe’s full recovery.

The clinic was convinced that the girl would not make it. But Arlene thought otherwise. She signed a waiver and brought her unconscious daughter home. At the advise of a friend, she decided to bring Fhoebe to the National Children’s Hospital (NCH) for a second opinion. It was only there that her child was rightly diagnosed -- Fhoebe has Stage 3 TB Meningitis.

After carefully studying Fhoebe’s case, NCH doctors and nurses informed her family that it was already too late for the child to recover, and it was time for them to let go. Arlene was

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The TB DOTS clinic staff at the NCH.

overwhelmed with fear of her daughter dying. She felt helpless. But one thing she never dared to think of in those moments was giving up.

“Mabubuhay siya (She will live),” Arlene bravely told herself and the others around her; believing that keeping strong for her child would make a difference. The event reminded Arlene of her birthing experience with Fhoebe, not of the physical pain of the actual childbirth, but of the feeling of readiness to endure anything given by the prospect of delivering a

life. And yes, she was prepared to do anything just to make her daughter live through. To her, the moment felt like she was birthing Fhoebe for the second time.

The nurses were inspired by Arlene’s courage, and took good care of her daughter. Then, to everyone’s surprise, nine-year-old Fhoebe woke up after twelve days of being in comatose.

Today, Fhoebe still takes medications under the TB DOTS program to assure her of full recovery. Fhoebe now shares her dream of becoming a nurse. When asked why, Fhoebe shyly answered, “Gusto ko pong alagaan ang mga may sakit na bata tulad ng pag-aalagang ginawa sa akin (I want to take care of sick children the way nurses in NCH did to me.).”

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Leaving No Stones Unturned

Melinda C. Santiago, RNTB Clinic NurseJose R. Reyes Memorial Medical Center (JRRMMC)

Due to limited local opportunities and meager salaries, thousands of Filipino nurses go overseas in the hope of alleviating their families from poverty. Only a few choose to stay to serve their country. 54-year-old nurse Melinda “Ate Baby” Santiago is one of those few.

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admitted TB patients by administering medications, making referrals to health centers, monitoring the patients’ conditions, and maintaining their records. “Wala pa kaming clinic noon, nasa isang sulok lang kami, naghihintay ng pasyente na ire-refer mula sa OPD at iba pang departments,” she recalled. Technically, her work as a TB-DOTS clinic nurse is only half-day as she also has work at the Department of Health - Central Office Infirmary. But since there is so much to be done at the TB clinic, she ends up staying there until evening, waiting for referrals or patient’s laboratory results. She runs to the Infirmary if there is urgent work to be done.“Lagari akong talaga. Pabalik-balik. Minsan, sabi ko, dapat may skateboard ako kasi

She has been working for public hospitals for 28 years. She is currently on her third year as nurse at the Jose Reyes Memorial Medical Center (JRRMMC) TB-DOTS clinic, and one of the key persons in making it number one in the CATCH-TB case findings in terms of external referrals.

Ate Baby was first employed by the Department of Health where she served for 15 years. She was eventually deployed to JRMMC after a re-organization. She was trained for the TB-DOTS program during the launch of CATCH TB in 2010, and was tasked to run its clinic in JRRMMC. Her job as a registered nurse is to provide hands-on care to both out-patients and

Jose R. Reyes Memorial Medical Center (JRRMMC)

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nakakapagod maglakad,” she jokingly stated. Everyday, Ate Baby assists around 10 to 20 patients in their Direct Sputum Smear Microscopy (DSSM). On top of that, she has more than 20 patients for follow-up per day. These are the people whom she has referred for treatment in local health centers. According to her, they do not come from Manila alone. There are cases from Leyte, Bohol, and other provinces, too, who are either pulmonary or extra-pulmonary TB patient.

Aside from taking care of the patients who come to their clinic, Ate Baby ensures that the patients she refers to other TB-DOTS facilities are continuously

taking their medications. “Kung may number ang health center, kinokontak ko sila para alamin ang outcome ng referral at kamustahin ang ang mga pasyenteng inirefer sa kanila. Pero tinatanong ko rin ang contact details ng pasyente, ine-explain ko na dapat malaman ko kung naggagamot sila o hindi.” (If the health center has a contact number, I inquire from them the outcome of a referral and if the patients referred to them are continuing their treatment. I also ask the patient their contact details and explain to them that I need to know if they are taking their medicines or not.”JRRMMC TB-DOTS Clinic

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namo-monitor ang tamang pag-inom. Napa-follow-up ang plema para makita kung gumagaling sila. (Health centers ensure proper drug intake. They also monitor the patient’s sputum to see if there are improvements.)”

Apart from the physical care that Ate Baby provides, she also gives emotional support to patients and their families. She educates them both regarding tuberculosis management and provides information on home care to guarantee the recovery of the patients and prevention of spreading the disease. She makes patient feel her personal care and according to her, work at the TB clinic gained her more friends.

Despite the daunting task of monitoring patients whether personally or remotely, Ate Baby joyously does her responsibilities. “Masaya akong makitang gumagaling ang mga pasyente ko (My happiness is to see them get better),” she said.

Being a naturally friendly and funny person, convincing patients to religiously follow the medication and to finish the six-month treatment is not really a challenge for Ate Baby. Almost all of them follow her every advise. However, there are still those who prefer to buy medicines for various reasons. “Kailangang mahikayat ko silang huwag nang bumili at pumunta na lang sa TB-DOTS clinics (I need to persuade them to go to TB-DOTS clinics instead of buying medicines and self-medicating),” she said. Ate Baby emphasized the importance of follow-up and monitoring in the TB-DOTS treatment. “Kapag nagsasarili ka ng gamot, hindi mo alam kung tama ang gamot na iniinom. Baka magkaroon pa ng drug-resistance (Taking medicines without guidance from TB-DOTS might result to multi-drug resistant TB),” she explained. “Sa health center,

Attending CATCH-TB meetings with TB-DOTS staffs from other hospitals

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With not enough farmland to till due to the growing commercialization of lands, thousands of Filipinos from remote provinces are forced to migrate to the city to look for work. One of them is Ian Arselon, 26 years old and a high school graduate. Ian hails from a family of farmers and the eldest of seven children. He moved to Manila with hopes of getting a job that would augment his family’s income.

Continuous Care

Ian ArselonWorker

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He was employed as a driver for a trucking company which required him to work for more than eight hours a day without overtime incentive. Ian endured this for eight months until he got ill. He started experiencing chest pains and began vomitting blood. His exposure to different elements during work coupled with poor living conditions in Pavia, Tondo where he shares a small room with his cousin, made Ian vulnerable to diseases like TB. Since their company does not provide health benefits for contractual employees, Ian said that their supervisor only advised him to undergo check-up at Jose Reyes Memorial Medical Center (JRRMMC) where he could at least access affordable medical services. The sputum tests conducted at the JRRMMC TB-DOTS clinic confirmed Ian’s tuberculosis. He was immediately prescribed to undergo a 6-month treatment process.

Ian’s health condition compelled him to leave work and focus on treating his illness. This also means going back to Masbate because he can no longer afford to live in the city. To ensure Ian’s continuous treatment, the TB-DOTS clinic, through its devoted nurse, Ms. Melinda Santiago, also known to patients as “Ate Baby” made a referral to the local Masbate health center. With the help of the TB-DOTS referral system, Ian can conveniently access medical care and claim his medicines at no cost. Ian has now completed his six months treatment and has been declared TB-free. He couldn’t be more thankful for the encouragement of his family and the TBDOTS program. He’s also particularly grateful for the support given to him by their local health workers and compassionate nurse like Ate Baby. Reenergized, Ian is now on the hunt for a new, worker-friendly job. His future plans include going to college once he has secured enough resources for enrolment.

Ian ArselonWorker

Ian returns every month to JRRMMC for his follow-up consultations

Investing for a TB-free society is a viable social capital. To do this, access to health services has to be democratized across economic classes. Evelyn Camarador believes that this can be made possible in hospitals and community-based health providers through the institutional support of different government and private agencies. Ms. Camarador is the National TB Control Program (NTP) Nurse Coordinator of the Amang Rodriguez Memorial Medical Center (ARMMC) in Marikina since 2004.

TB-DOTS as a Viable Social Capital Investment

Evelyn F. Camarador, RN, MANNurse SupervisorHEPO DesignateNTP Nurse CoordinatorAmang Rodriguez Memorial Medical Center (ARMMC)

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As such, she oversees all promotive and preventive health programs of the ARMMC. She witnessed the progress of the TB-DOTS clinic from its NTP predecessor.

Albeit not an easy task, Ms. Camarador formally joined the TB-DOTS program in 2004. Due to the strong stigma on TB, no one wanted to volunteer for the program. But Ms. Camarador was willing to undergo training. She recalled that her position was temporary and expecting to be replaced right away, but she is still in the program until the present.

The program took off with a single nurse responsible for the Marikina area but joined by two more

health providers soon after. Ms. Camarador was soon engaged in serving patients and conducting seminars and training. The increasing patients in the TB-DOTS clinic prompted her to train more volunteers for TB-DOTS. However, some trainees eventually transferred to the hospitals or found jobs overseas. Despite the challenges, initiative

and resourcefulness kept the program going. Most importantly, dedicating time and energy and serving those in need is the key factor for the success. “Indeed I really have a heart for TB because I came from a communicable-disease hospital,” said Camarador. She started working in San Lazaro hospital so she had the necessary background to scientifically understand how to handle the disease and the stigma that goes with it. Fully aware of the implication of having patients with untreated TB, she and her staff would at times find themselves searching for symptomatic patients who did not return to begin their treatment.

From the time TB-DOTS started, the supply of medicine for adult patients has been reliable. In 2011, the clinic

Amang Rodriguez Memorial Center (ARMMC) Out-Patient Deparment

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started getting supplies for anti-TB drugs for children. “Children are at risk whenever they have adult companion at home who are confirmed TB patients. Due to this, we now have more patients to treat in our clinic,” Ms. Camarador claimed. She took this opportunity to ask for additional staff to meet the rising demand.

Ms. Camarador has learned to devise proactive strategies like requiring that each TB patient have a companion who shall stand as secondary treatment partner at the onset of their medication. A secondary treatment partner shall help ensure that the patient is properly taking medications during the prescribed treatment duration. This method has proven very effective in the treatment success of many under their care especially the co-morbid patients. She also sends text messages to remind her patients about their medication.

In the nine years of TB-DOTS service in ARMMC, it provided free health assistance for the marginalized sectors of Marikina and Rizal. The staff of health centers in Rizal collaborated with the hospital in finding patients for the program. They have also assisted in encouraging hospitals in Rizal to participate in the program, this would help greatly in providing Rizal constituents better access to treatment and free medications without having to travel a great distance to get their free medicines.

However, more medical centers have to be engaged in order to accommodate more patients. As of the present, there are still hospitals that are apprehensive of the program despite the

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of the disease. All of these can help translate to higher cure rate. Reviewing the TB-DOTS registry, Ms. Camarador shared that the ARMMC has contributed 1,400 patients who has “graduated” from TB treatment, which increase every year as more people become aware of the program.

Indeed, the best practices from the ARMMC can help bolster the credentials of medical practitioners, health centers and hospitals, while fulfilling their vow of serving the society. A nation with a sound social capital gets to reap the return of investment in the future. ARMMC’s success can be every one’s story if more government and private hospitals join the grassroots communities in the fight against tuberculosis.

government’s mandate to implement the TB-DOTS Program. Ms. Camarador states, “I don’t understand how hospitals are willing to implement new programs but not the TB-DOTS.” To allay the said hesitation, she further explains that the support system for the project has already been established. The NTP has provided medical equipments such as microscopes, laboratory supplies and drugs. The CATCH TB Cases Projects conducted trainings and orientations. One just has to have the willpower to kick-off the program until it fully functions. “Dati nasa ilalim lang kami ng hagdanan naghihintay ng pasyente na ire-refer sa amin (We started off with a table near the staircase, waiting for patients to be referred to us)”, she recalled. Soon the hospital saw the need to provide TB-DOTS a better space with the increasing number of patients to attend to. Now, they have a place of their own. In fact, they are expecting an expansion as they are awaiting the finalization of the adjacent room to be used for laboratory purposes.

Ms. Camarador hopes that more hospital can soon be engaged in the program. Ridding the society of TB can only happen if more health care providers can accurately diagnose TB, provide proper medication and help address the stigma with better knowledge

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Surpassing TuberculosisSalvacion “Vacion” Domo, 29, keeper of a small sari-sari store and eatery, was diagnosed with tuberculosis (TB). After enduring six months of regular and strict medication under the TB-DOTS program in Barangay Maligaya Health Center, Vacion is now cured.

Salvacion DomoStore owner

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diagnosed with TB. Jose’s condition required the rest of their family to undergo check-up for TB. That was how Vacion discovered that she, too, was infected. To make matters worse, her toddler son, Sean, was also diagnosed with the same illness.

Vacion was distressed by the news. Her brother was only 13 years old then, and her son was only three. These boys are too young and their body too fragile to suffer from the dreaded disease. She cannot afford to be sick because she is the one providing for her family. And given the kind of livelihood that they have, the stigma on TB will definitely affect their clientele. They had to recover the soonest time possible.

Vacion immediately went to the nearest private clinic. She opted to go there because there was always a doctor, unlike in some health centers where the physician

According to studies conducted by the World Health Organization, TB is a disease of poverty and it mostly affects adults in their productive years. Statistics show that more than one third of the world’s population is infected with TB bacilli, the microbes that cause TB. Vacion was one of them.

It was July 2011 when Vacion’s younger brother, Jose, was taken to the Lung Center of the Philippines (LCP) after experiencing series of seizures. Her brother was

Maligaya Health Center

Vacion referring to her patient ID card

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only visits once a week. But the private clinic charges a consultation fee and the patients have to buy their own medicines. Aware that the treatment will last for six months, Vacion knew that her meager income would not suffice for the three of them. Fortunately, after Vacion’s brother was discharged from the LCP, the hospital issued them a referral to Barangay Maligaya Health Center, the nearest public clinic in their community that offers TB-DOTS treatment. Medicines under the TB-DOTS are provided to the patients at no cost. They just need to strictly follow the daily treatment plan.

“Dapat alagaan ng mga tao ang

kalusugan nila para sa mga bata.

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It was mandatory for them to go to the health center every single day to get their daily dose of cure. TB-DOTS was programmed this way so that nurses could monitor the patients’ medicine intake.

Vacion patiently followed what was prescribed of them. She regularly visits the Maligaya Health Center to take her medicines, as well as get the scheduled drug for her son. Meanwhile, Jose also drops by the clinic every afternoon after his class. Six months later, due to their determination to get better through the TB DOTS program, they were able to survive tuberculosis.

According to Vacion, the whole experience taught her one of the greatest lessons in life, she said, “Dapat alagaan ng mga tao ang kalusugan nila para sa mga bata. Maselan pa ang katawan ng mga musmos, at puwede silang mahahawa sa sakit ng matatanda. (Adults should take care of their health not for themselves but for the children. The young ones’ well-being is very delicate and is always at stake whenever unhealthy grown-ups surround them.)”

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Acknowledgements

Physcians Daphne D. Bate, MD, FPCP, FPCCP, MsPHRegina P. Berba MD, MSc., FPCP, FPSMID

Victor J. Dela Cruz, MD, CESO IV Margery R. Genabe, MD

Rosalind G. Vianzon, MD, MPH

NursesEvelyn F. Camarador, RN, MAN

Melinda C. Santiago, RN

PatientsIan Arselon

Salvacion DomoPhoebe Shane Ganancial

Arlene Ganancial

TB-DOTS StaffNational Children’s Hospital TB-DOTS Staff

UP PRIME TB TB-DOTS StaffJRMMC TB-DOTS

Quezon City General Hospital TB-DOTS StaffTondo Medical Center TB-DOTS Staff

San Joaquin TB-DOTS