|Year : 2019 | Volume
| Issue : 2 | Page : 180-184
Referral and treatment outcomes of tuberculosis patients who crossed the border from Japan to the philippines
Akihiro Ohkado1, Aurora Querri2, Tamae Shimamura3, Masaki Ota3, Anna Marie Celina Garfin4
1 Department of Epidemiology and Clinical Research, Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Kiyose, Tokyo, Japan; Research Institute of Tuberculosis/Japan Anti-Tuberculosis Association, Philippines, Inc., Manila, The Philippines
2 Department of Epidemiology and Clinical Research, Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Kiyose, Tokyo, Japan
3 Department of Technical Assistance, Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Kiyose, Tokyo, Japan
4 National Tuberculosis Control Program, Bureau of Disease Prevention and Control, Department of Health, Manila, The Philippines
|Date of Web Publication||14-Jun-2019|
Department of Epidemiology and Clinical Research, Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Matsuyama 3-1-24, Kiyose, Tokyo 204-8533
Source of Support: None, Conflict of Interest: None
Background: The referral and treatment outcomes of tuberculosis (TB) patients referred from Japan to the Philippines have not yet been systematically reported. This study aimed to describe the cross-border referral process for TB patients referred from Japan to the Philippines. Methods: This is a retrospective descriptive review of the referral process between the two countries. The data on the pathways of Filipino patients with TB or latent TB infection initially treated in Japan from 2009 to mid-2018 were summarized. We calculated the proportion of the referred-and-accessed and that of the successfully treated in the health facilities in the Philippines. The Chi-square test or Fisher's exact test was applied to test significant differences between categorical data. Results: Among the 36 Filipino TB patients referred, 83.3% (30 patients) were successful in accessing any of the health facilities. Among these, 28 patients confirmed that they had started TB treatment in the Philippines. Age groups (P = 0.17), gender (P = 0.76), planned place of residence (P = 0.44), bacteriological results (P = 0.81), and TB patient types (P = 0.96) did not show any significant differences in the referred-and-access rate. The treatment success rate among the 23 TB patients (excluding five patients who were still receiving treatment as of writing) was 91.3%. However, only three out of five multidrug-resistant TB patients successfully started treatment. Conclusions: The current cross-border TB patient referral mechanism between Japan and the Philippines indicated successful results. However, it needs to be enhanced by strengthening the mechanism to track referral outcomes systemically.
Keywords: Continuity of patient care, mechanism, pathway, tuberculosis
|How to cite this article:|
Ohkado A, Querri A, Shimamura T, Ota M, Celina Garfin AM. Referral and treatment outcomes of tuberculosis patients who crossed the border from Japan to the philippines. Int J Mycobacteriol 2019;8:180-4
|How to cite this URL:|
Ohkado A, Querri A, Shimamura T, Ota M, Celina Garfin AM. Referral and treatment outcomes of tuberculosis patients who crossed the border from Japan to the philippines. Int J Mycobacteriol [serial online] 2019 [cited 2019 Sep 18];8:180-4. Available from: http://www.ijmyco.org/text.asp?2019/8/2/180/260383
| Introduction|| |
The annual notification rate of tuberculosis (TB) patients in Japan, which has been declining by approximately 4%–6% per annum in the past years, reached a level of 13.3 per 100,000 population in 2017. The age of TB notified patients in Japan has been progressing, which is reflective of the age progression of Japanese people. Contrastingly, the number and proportion of foreign-born TB patients have been increasing; in 2017, the number and proportion of foreign-born TB patients were 1530 and 9.1%, respectively. The proportion was still below 10%, but it amounted to nearly two-thirds of the 20–29 years' age group. The top five countries of origin of the foreign-born TB patients in Japan were the Philippines, China, Vietnam, Nepal, and Indonesia.
Cross-border TB patient referral has become an issue because many foreign-born patients receiving TB treatment intend to return to their countries of origin from Japan once they become non-infectious., It is estimated that 343 foreign-born TB patients among 4179 foreign-born patients notified between 2011 and 2015 moved out from Japan internationally. Uninterrupted TB care provision is of paramount importance for all TB patients irrespective of the place they receive this care. The use of insufficient TB medication by TB patients is one of the critical risk factors for the emergence of drug resistance that hampers TB treatment globally., Hence, whenever a patient receiving TB treatment moves from one place to another, we need to ensure that they continue their treatment after moving out., In general, it is considered beneficial for patients to receive TB treatment in the health facilities where they started TB treatment, at least until the end of the intensive phase. It is one of the challenges in ensuring uninterrupted TB treatment and care even inside a country; thus, the establishment of a quality referral mechanism across countries is more demanding. So far, no official agreement has been made between Japan and the Philippines on a cross-border TB patient referral mechanism; therefore, treatment outcomes of referred TB patients have not yet been systematically reported.
The Research Institute of Tuberculosis (RIT), Japan, in collaboration with the RIT/JATA Philippines, Inc., (RJPI), a local non-governmental organization (NGO) that aims to improve TB patient care in urban settings in the Philippines, has been coordinating referrals of TB patients between the local health offices in Japan and the TB treatment sites in the Philippines since 2008. This study aimed to describe the referral and treatment outcomes of TB patients who crossed the border from Japan to the Philippines during their treatment.
Study population and methods
This study is a retrospective descriptive review. Data on the pathways of Filipino patients with TB or latent TB infection (LTBI) who were initially diagnosed and received TB treatment in Japan from 2009 to mid-2018 were summarized. Basic TB patient profiles such as age, gender, place of residence in the Philippines, and characteristics of TB were collected in addition to details regarding the referral process. The RIT staff start communicating with the RJPI staff soon after a local health office in Japan contacts the RIT regarding a Filipino TB patient referral. The RIT staff members also request the local health staff in Japan to obtain informed consent from the TB patients for sharing data with the staff in the Philippines; they are also requested to fill a patient treatment card which is received by physicians at the other destination. The informed consent form contains subtitles of title, purpose, methods, confidentiality, benefits, agreement, and the contact person's name and address. The RJPI performs initial coordination with health workers in the Philippines and follows patients and health staff via any form of communication to track and ensure access to and completion of patients' TB treatment in the Philippines. A chronological pathway of TB patients referred from Japan to the Philippines is shown in [Figure 1].
|Figure 1: A cross-border referral pathway of tuberculosis patients from Japan to the Philippines. TB: Tuberculosis, RIT: Research Institute of Tuberculosis, Kiyose, Japan, RJPI: Research Institute of Tuberculosis/Japan Anti-Tuberculosis Association Philippines, Incorporated, Manila, Philippines|
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The following measurements that indicated the pathway of the cross-border TB patient referral were calculated: the proportion of patients who accessed a health facility in the Philippines among those who were referred (hereinafter referred to as the referred-and-access rate); the proportion of those who continued TB treatment in the Philippines among those who were referred and accessed (the TB treatment initiation rate); and the proportion of those who successfully completed TB treatment among those who continued TB treatment in the Philippines (the TB treatment success rate). Chi-square test or Fisher's exact test was applied to test significant differences between categorical data; P = 0.05 was considered statistically significant.
The Institutional Review Board at the RIT, Kiyose, Japan, approved this study in 2013 (Reference number: RIT/IRB 25-20).
| Results|| |
We assisted with the referral of 36 Filipino TB patients from 2008 to mid-2018. Among the 36 TB patients referred, 61% (22 patients) were men, with a median age of 34 years, and 36% (13 patients) planned to return to their residence in Metro Manila. There were five multidrug-resistant TB patients (MDR-TB) and two LTBI patients [Table 1].
|Table 1: Profiles of the Filipino Tuberculosis patients referred from Japan to the Philippines, 2008-mid-2018 (n=36)|
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Of 36 patients, 83.3% (30 patients; the overall referred-and-access rate) were successfully referred and had accessed any of the health facilities in the Philippines [Figure 2]a. One of the six referred-but-not-accessed TB patients was an MDR-TB patient who was lost to follow-up. Age groups (<35 years vs. ≥35 years, P = 0.17), gender (males vs. females, P = 0.76), planned place of residence (in Metro Manila vs. in other places, P = 0.44), bacteriological results (positive vs. negative, P = 0.81), and TB patient types (new bacteriologically positive pulmonary TB vs. new clinically diagnosed pulmonary TB vs. MDR-TB vs. others, P = 0.96) did not show any significant differences in the referred-and-access rate.
|Figure 2: (a) State of the access to a health facility and treatment initiation of the 36 Filipino tuberculosis patients referred from Japan to the Philippines, 2008 to mid-2018. (b) Treatment outcomes of the Filipino tuberculosis patients referred from Japan to the Philippines and accessed to a health facility, initiated treatment in the Philippines, 2008 to mid-2018|
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Among the 30 successfully referred-and-accessed TB patients, 93.3% (28 patients; the overall TB treatment initiation rate) confirmed that they had initiated treatment in the Philippines [Figure 2]a. One of the two accessed-but-not-initiated TB patients was another MDR-TB patient who refused to initiate TB treatment in the Philippines. No patient characteristics indicated any significant difference in the TB treatment initiation rate (data not shown).
The median number of days between some of the critical time points in the referral process is indicated in [Table 2]. The RJPI staff communicated with the concerned agencies in the Philippines immediately after receiving contact from Japan.
|Table 2: Intervals between critical points in the referral process of the 36 Filipino tuberculosis patients referred from Japan to the Philippines, 2008-mid-2018|
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Five TB patients, including two MDR-TB patients, were still receiving treatment at the time of writing. The overall TB treatment success rate among the 23 TB patients who had terminated treatment was 91.3% (21 patients); however, two TB patients, including one MDR-TB patient, were lost to follow-up [Figure 2]b. Of the five MDR-TB patients referred from Japan, four were able to access any of the health facilities in the Philippines, of these only three initiated MDR-TB treatment, following which one of the three was lost to follow-up; the remaining two patients were still receiving MDR-TB treatment at the time of writing.
| Discussion|| |
From 2009 to mid-2018, we coordinated the referrals of 36 Filipino patients with TB or LTBI who had initiated treatment in Japan and then came back to the Philippines, of which 30 (83%) successfully accessed health facilities in the Philippines. Among these 30 patients, 28 patients confirmed that they had initiated TB treatment in the Philippines, indicating a relatively high treatment initiation rate. The treatment success rate among the 23 TB patients (excluding five who were still receiving treatment) was 91.3%. Dara et al. had proposed some initiatives to ensure transnational TB patient care in the United States. The TBNet, currently the Health Network, reported that the treatment completion rate of all the TB patients they had handled was consistently over 84% in the past decade. The treatment success rate found in this study was comparable to the data they had reported although the Health Network handles a much larger number of TB patients (more than 100 per annum) than we encountered.
The median number of days between the day of arrival in the Philippines and the day of actual visit to a health facility for the 30 successfully accessed Filipino TB patients was 13 days. This implies that approximately 2 weeks after arrival, it may be critical for a TB patient to visit a health facility.
Although it was beyond the scope of the present study for which we did not have any means to find and interview lost-to-follow-up TB patients, we need to investigate the reason why some of the referred TB patients did not access a health facility after arrival or did not initiate TB treatment after accessing a health facility. Even though the overall referred-and-accessed rate and treatment success rate were reasonably high, we lost six referred patients. This drawback of the referral process increased the demand for enhancement, especially at the early stage of the cross-border TB patient referral mechanism. The RJPI staff members asked the local health staff to trace the referred patients by a phone call to find out if they had accessed a health facility. More intensive care like a home visit may be needed to enhance the process.
Three out of the five MDR-TB patients referred from Japan to the Philippines could not be successfully treated in the Philippines. This observation indicates that it is relatively difficult to ensure TB patient uninterrupted care across countries, especially for MDR-TB patients. The proportion of MDR-TB coinfected with human immunodeficiency virus (HIV) has been reportedly increasing in Manila, the Philippines. Hence, we may also have to take the possible HIV coinfection among Filipino MDR-TB patients into account. We need to develop some innovative cross-border TB patient care mechanisms designed explicitly for MDR-TB patients and probably for HIV coinfected MDR-TB patients as Sub-Saharan African countries encounter. Such innovative techniques may include more intensive, frequent, and patient-oriented care and communication.,
The present study has some limitations. First, we only described the TB patient referral pathways for Filipino TB patients for whom we were asked to arrange continuous TB treatment. The Filipino TB patients we assisted would only make up a small proportion of TB patients who went back to the Philippines during their TB treatment. Hence, the findings of this study must be interpreted with care. Second, we, as members of an NGO, had been communicating constantly with the concerned agencies in the country. This intensive effort may have increased both the referred-and-accessed rate and treatment success rate in the field. Therefore, the findings of this study may overestimate the effectiveness of the present referral mechanism. However, this could be a strength of the study as the RJPI, an NGO, was able to act as a proactive link between government organizations and referred TB patients.
The critical role players that serve as linkage bodies in the current mechanism are the RJPI in the Philippines and the RIT in Japan; both these were bodies of NGOs. There are at least two questions with regard to the sustenance of the mechanism: first, who takes on the roles of the linkage bodies, NGO like the RJPI in the destination country and the RIT in the sending country? and second, who should pay to maintain this mechanism? The Cure TB Referral Program in the United States presents a sound example., The program initially started off to enhance the linkage of TB patient referral between the United States and Mexico and then expanded between the United States and other countries in the world (Kathleen Moser, personal communication). Currently, the Cure TB Referral Program makes use of the National TB Control Program (NTP) network in each of the destination countries. However, we feel it would be better for the receiving countries to have a coordinating agency like the RJPI in the Philippines instead of asking the NTP to act as the coordinating body because of the limited human resources in the NTP in general. The International Organization for Migration (IOM) could potentially play a significant role in settling international migrants with TB in their country of origin (Predrag Bajcevic, personal communication). Establishment of a rigid cross-border TB patient referral mechanism interlinked with an international organization like the IOM could enhance both domestic and international local health systems and patient-centered TB care.
| Conclusions|| |
The current cross-border TB patient referral mechanism between Japan and the Philippines showed successful results. However, it needs to be enhanced further with regard to strengthening the mechanism of tracking referral outcomes, especially of referred MDR-TB patients.
The authors extend sincere thanks to all health staff both in Japan and in the Philippines involved in the pathways of the Filipino TB patient referrals with regard to the present study for their kind and patient commitment and support.
Financial support and sponsorship
This study was funded in part by a research project of the International Medical Center of Japan, “A socio-medical study for facilitating effective infectious diseases control in Asia” funded by the International Medical Cooperation Grant, the Ministry of Health, Labor and Welfare, Japan; the Health, Labour and Welfare Sciences Research Grants, of the Ministry of Health, Labour and Welfare, Japan, Grant Number 28040101; and the Double-barred Cross Seal Donation Fund of the Japan Anti-Tuberculosis Association, Japan.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]