IT was on a fine summer day in May on the island of Tingloy in Batangas when officials of the Department of Health (DOH)-Calabarzon (Cavite, Laguna, Batangas, Rizal, Quezon) launched a noble program with one single-minded objective: Decisively end the prevalence of tuberculosis (TB) disease that afflicts a good number of island residents.
Launched on May 2, 2019, TANGLAW, or “TB Agapan, NGayon Lunasan at Wakasan,” is the first TB-Free island initiative in the country with the objective of eliminating tuberculosis in island municipalities of the region. The total budget for the activities of the program in Tingloy is P571,500 when it started in 2019. TANGLAW was also launched later on Polillo Island in Quezon on September 26, 2019.
Derived from the Filipino word tanglaw, or torch, that shines a light to a darkened path, the DOH-Calabarzon’s program aims to bring hope and heal those on the island afflicted with the dreaded but curable respiratory disease.
To avoid being stigmatized, not only the chest X-ray screening, GX testing were undertaken, but a medical and surgical mission was also conducted for Tingloy residents. This included random blood sugar (RBS), body mass index (BMI) and blood pressure (BP) measurement, urinalysis, hemoglobin testing, newborn screening blood testing, circumcision, dental service, medical consultation, buntis check-up, smoking-cessation seminar, and provision of multivitamins and medicines for children and essential and maintenance medicines for adults. Dental and buntis kits were also distributed. The same approach was replicated on Polillo.
“So, they went there not only because they will be screened for TB. This is to avoid the stigma,” DOH-Calabarzon Regional Director Dr. Eduardo Janairo said.
In an interview, Dr. Maria Elena G. Castillo-Gonzales, head of the Regional Infectious Disease Cluster, said TANGLAW was presented during the National Tuberculosis Control Program (NTP) consultative meeting in 2019.
Dr. Gonzales, who also coined the TANGLAW acronym for the program, said that each region would present a plan as part of their commitment to the 2017-2022 Philippine Strategic TB Elimination Plan.
“Our goal is to end TB. So the goal of the program is very ambitious, TB elimination right away…. We need to be anchored…each and every region has its own individual plans,” she said.
She recalled that during the planning stage in 2018, before the consultative meeting in 2019, their initial goal was to conduct active case finding (ACF).
Dr. Gonzales said that when they presented the plan, Janairo suggested launching it in island municipalities.
“So, our plan to have a TB -free program with active case finding became a TB-Free Island [initiative],” Dr. Gonzales said. From then, the NTP core team of the DOH-Calabarzon, composed of Dr. Gonzales; Kristine Marie I. De Guzman, nurse outcome manager; and Ms. Ma. Cristina Ann N. Buenaagua, medical technologist outcome manager, did not waste any time and immediately held brainstorming sessions.
According to Dr. Gonzales, the TANGLAW program has four implementation phases.
Phase 1 includes the preparations. Interim guidelines were also created. Dr. Mariquita Mantala, in-country advisor, was a big help in drafting the initial plans.
As part of the preparations, Dr. Gonzales said, they needed to look at the logistics, supply, health human resources, and general demography of Tingloy, a fifth-class municipality of Batangas province, which includes Maricaban Island, Caban Island and other minor islets located south of the Calumpang Peninsula, with a population of around 20,000.
The DOH-Calabarzon said their data showed that in Tingloy, there were 69 TB positive patients on the island and an additional 21 positive cases identified from January up to April 30, 2019.
“We have chosen to start the project in Tingloy because it is one of the areas in Calabarzon where cases of tuberculosis are high and continue to increase,” Dr. Janairo said.
Dr. Gonzales also said that Tingloy and Polillo were chosen for the implementation of Tanglaw because “there are UHC [Universal Health Care] implementation sites in Batangas and Quezon.”
Under Phase 2, a massive TB screening of all the population of the island, from children to adult, will be conducted.
Once diagnosed, they will be enrolled in the program and treated promptly to keep the illness from progressing and prevent further spread of infection in the community.
There will also be a mapping system to have a geographical information system and visual presentation for them to be easily located by health-care workers.
“This is also to ensure the continuity of TB treatment completion,” Janairo emphasized.
Prevention is under Phase 3, Gonzales continued.
“There are already TB cases, so how will you prevent this? This is where TB preventive therapy will come,” she said, citing that therapy plays a crucial role in efforts to eliminate TB and prevent latent infection from progressing.
Phase 4, she said, is TB elimination.
“We are still far from achieving that [TB elimination phase],” she said, adding that currently, and due to the pandemic, TANGLAW remains in Phase 2.
Covid-19 response takes its toll
Dr. Gonzales lamented that the Covid-19 pandemic has impacted the “smooth sailing” implementation of the TANGLAW program.
Everything was well planned until the pandemic came, she recalled.
Gonzales noted that Covid has also affected other TB programs in the country, not only TANGLAW.
Health Secretary Francisco T. Duque III said that they see a direct effect of the Covid-19 pandemic “on a critical disease prevention and control program like TB” after the NTP reported that from January to March this year, there were a total of 88,662 new and relapse TB cases, declining steeply by almost 20 percent between February (30,728) and March (24,782).
“The quarantine has extremely affected and limited the health-seeking behaviors of our fellow Filipinos,” Duque said.
Dr. Gonzales said that bringing equipment to both islands alone already poses a challenge.
“Buwis-buhay talaga [Your life is almost at stake every time because] going there is not so easy,” according to Gonzales.
Amid the pandemic, Dr. Patt Flexl Mandocdoc, DOH Doctor to the Barrio on Tingloy Island, said they are still making sure that they can continue to monitor those enrolled in the program.
However, their ACF has been affected due to quarantine restrictions.
One of the challenges, Dr. Mandocdoc said, is managing the dwindling medical supplies or lack of supplies, at times, for pediatric age group. They get the medicines for children through a Korean non-governmental organization (NGO), the Good Neighbors International Philippines.
The supply for adults, meanwhile, comes from the DOH, while the local government of Tingloy helps in the operations side of the program.
Mandocdoc said they are thankful that the lack of a radio technologist in Tingloy was addressed early this year, accelerating implementation of the program.
When it comes to his patients, Mandocdoc said that after one who’s been identified as a positive case wants to enroll in the treatment, that patient gets a full briefing on what he or she will experience while undergoing treatment.
“It requires careful monitoring as well,” Mandocdoc said, stressing that they have to make sure that the TB patient will not pass the disease on to other family members and other close physical contacts.
They must also be sure to look for signs that the patient is responding to the treatment.
As a doctor, one of the challenges he considers is when patients cannot handle the side effects of the drugs that they prescribe.
“If they can’t handle the side effects, sometimes they discontinue the treatment,” he said, stressing that any doctor will find this frustrating.
“We don’t want them to return when their TB is getting worse like they are coughing up blood already,” he said.
In May this year, Che (not her real time), 23, observed that she tended to feel tired and is always gasping for breath while working.
She decided to see a doctor. She had a chest X-ray and a sample of her sputum was also collected.
When the doctor informed her that she was afflicted with TB, she was speechless. She then informed her mother who was in Tingloy.
“I decided to go home in Tingloy and left my work in Batangas. I thought that it would be better to have my treatment there because I know there is TANGLAW there,” she said in Filipino.
When she started her treatment, she complained that she couldn’t handle her dizziness.
“It was hard. But I can tolerate the side effects now,” Che added.
However, Roy, 42, said he did not experience any side effects.
“I just feel normal,” he said. He first discovered that he has TB after he went to the Rural Health Unit to consult for his constant coughing.
He said he was unsure where he might have contracted TB. His wife was also screened but was negative.
Dr. Mandocdoc then asked him if he wants to enroll in the program and explained the process of treatment.
“I did not hesitate,” he said.
Dr. Mandocdoc said Roy is one of the patients who, after a few months, are already responding positively to the treatment.
“They are already gaining weight. No more cough but they need to finish the duration of the treatment,” Dr. Mandocdoc said. Roy is set to finish his treatment next month.
Dr. Janairo said that TB easily spreads from person-to-person contact through the air.
“When a TB positive person coughs, sneezes and speaks, the bacteria is released into the air where it stays for hours. If you will inhale it, you will be exposed and the possibility to contract TB is there, so you need to see a doctor immediately,” he added.
Both Che and Roy are thankful to the nurses and barangay health workers (BHWs) who were constantly reminding them to take their medicines and monitor them regularly.
“They would call us and remind us never to skip our medicines and remind us of our monthly check-ups,” she said, adding that they can also save money because not only are the medicines free: the BHWs personally bring these to them.
Dr. Mandocdoc said that the BHWs sign the patient’s ID treatment card system to determine if they have taken their medicines every day.
“Sometimes, the BHWs go to the patient to personally see that he or she is taking the medicines…sometimes they also count the medicines left just to be sure,” he added.
Che and Rey said that they did not feel embarrassed or ashamed despite contracting the disease because due to the pandemic, almost everyone stays at home. People will not wonder why they are not going outside their homes, they said.
Dr. Janairo also thinks the quarantine restrictions helped in containing the TB infection.
For his part, John Oliver Villegas, Development Manager Officer IV in Tingloy, stressed the importance of “correct information and family support” are also taught to them.
“Also the awareness that there is already TANGLAW wherein the treatment is free,” he said, noting that they no longer need to ride a boat to go to Batangas City for TB screening or treatment, because TANGLAW had came to the island, relieving them of the “catastrophic cost.”
He also noted that efforts of BHWs are immeasurable for they are also attending to Covid-19 response in the municipality.
Meanwhile, Maria Concepcion G. Macaraig, a barangay councilor of Barangay 15, Poblacion 3, considers TANGLAW a big help in the municipality, making the lives of TB patients a lot easier while they heal.
A former barangay nutritionist, Macaraig also helps monitor the distribution of medicines to TB patients in her barangay.
“There is no reason for TB patients to refuse treatment as everything is being provided for them for free,” she said.
Enrolled in TANGLAW
There were 139 patients enrolled in TANGLAW in Tingloy; two had discontinued; four died, and six were lost to follow-up.
In 2021, there were 37 additional TB patients, cured: 3, completed: 2, died: 1, and lost to follow-up: 1. There are 30 other patients currently undergoing treatment
On Polillo, meanwhile, the total number of persons screened stands at 1,818. Of this number 103 with chest x-ray findings, but only 15 have enrolled in the program.
TB isolation facility
Dr. Janairo, for his part, explained part of the plan is to put up a TB facility for drug-resistant TB patients.
However, there’s this possibility that this may not materialize at the moment due to the pandemic.
He also expects to see the progress of his “brainchild,” and if possible achieve TB elimination in Tingloy before retiring from government service.
The DOH-Calabarzon said TANGLAW was made possible through the NTP partners like local executives of Tingloy and Polillo, the private sector, and non-governmental organizations.
These are: USAID’s TB Innovations and TB Platforms, Philippine Business for Social Progress for Advancing Client-Centered Care and Expanding Sustainable Services for TB, and Gerry Roxas Foundation and Dr. Rajendra Prasad Hubraj Yadav, medical officer of World Health Organization.
Dr. Janairo said TANGLAW does not only “spark hope” for the island regions through the bayanihan spirit with the help of the government, NGOs, private sector and down to the community.
“Whole of society and whole of government approach. During my PHC [Primary Health Care] days, inter-local and intra-local collaboration,” Dr. Janairo said.
If TANGLAW would prove to be a success, Dr. Janairo expressed optimism that it will be replicated in other island municipalities or remote areas in the country.
This story supports the #TBFreePH campaign of the Department of Health. With the help of the United States Agency for International Development, #TBFreePH aims to increase and improve conversations about TB and help address stigma and discrimination experienced by persons with TB.