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Multidrug-resistant tuberculosis in the Philippines: totem and taboo

Posted by plosmedicine on 31 Mar 2009 at 00:01 GMT

Author: Jose Luis Portero
Position: Internal Medicine
Institution: No affiliation was given
Additional Authors: Maria Rubio
Submitted Date: October 27, 2006
Published Date: October 30, 2006
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Tupasi TE et al. [1] show the feasibility and cost-effectiveness of treating multidrug-resistant tuberculosis (MDR-TB) in a resource-limited setting. These conclusions can lead to error since the tertiary hospital where the pilot project was carried out is not representative of the average health care setting available for the Filipino tuberculosis patient.

Resch SC et al. [2] highlight that this analysis is not an independent evaluation and that the intervention was set in ideal conditions. In the field, this pilot project will find serious difficulties to be implemented within the Filipino National Tuberculosis Program (NTP), run by the government, where the majority of tuberculosis patients are diagnosed and treated. Moreover, in recent years Filipino tuberculosis health policy has not supported the development of capacities for mycobacteria culture and susceptibility test in the public regional laboratories, missing the opportunity to strengthen the competences on tuberculosis resistance management in the whole country. Taking into account the geography (an archipelago) and the structure of the NTP, a community-based pilot project carried out by the governmental health centers closer to the patients could have been more appropriate to study the feasibility and the real cost-effectiveness in a resource-limited setting.

The selection of 118 patients out of 171 eligible may bias the final results increasing the cure rate, since the most difficult patients to treat, by any circumstance, are also more problematic to enrol. A long-term follow-up of the patients may modify the final cure rate. It would have been important to analyse if any failure patient developed further resistances during the treatment and the public health implications of those as well as a more in-depth discussion of the resistance patterns and its relationship with the tailored treatment and the final outcome. Identification of independent variables linked with favourable outcome are needed to design future strategies. On the other hand, the absence of data about the HIV status of the patients is remarkable, considering the ideal conditions of the study and the increasing number of cases in the Philippines.

Cost-effectiveness analysis may be holistic and may contemplate MDR-TB control program with the rest of activities of the NTP in order to evaluate the convenience and priority of each intervention.

Unfortunately, the study does not support comprehensible strategies to control MDR-TB in the community. Patients, families, social activists and health personnel related to tuberculosis control can input important points of view. A big consensus may avoid that MDR-TB control switches from taboo to totem.


1. Tupasi TE, Gupta R, Quelapio MID, Orillaza RB, Mira NR, et al. (2006) Feasibility and cost-effectiveness of treating multidrug-resistant tuberculosis: A cohort study in the Philippines. PLoS Med 3(9): e352. DOI: 10.1371/journal.pmed. 0030352

2. Resch SC, Salomon JA, Murray M, Weinstein MC (2006) Cost-effectiveness of treating multidrug-resistant tuberculosis. PLoS Med 3(7): e241. DOI: 10.1371/journal. pmed.0030241

Competing interests declared: We declare that we have no competing interest