Future directions for notifiable diseases: tuberculosis-related laws in the Philippines

The Philippines is one of 22 countries with the highest TB burden that collectively account for more than 80% of reported TB worldwide. The Philippines has a population of 99 million and has a high burden of TB, with an estimated 290,000 new TB cases each year [17]. The estimated incidence of newly diagnosed TB annually was 324 per 100,000 persons in 2015 [22], and TB-related mortality was 33 per 100,000 persons in 2010 [15].

TB continues to be the sixth leading cause of death despite the long-standing public health prevention efforts made by various units of the Philippine government. The Philippines ranks fifth among the 27 priority countries with a high burden of multidrug-resistant TB (MDR-TB) [6], and MDR-TB has become a serious public health problem [5, 6] Currently, the number of patients enrolled for treatment only includes 25% of the estimated 12,000 MDR-TB cases [17].

A public health service package supported by the government is outlined by PhilHealth, a national health insurance scheme of the Philippines that covers 38% of the population. Services covered are not comprehensive, co-payment is high, and the reimbursement procedure is complex. Private services are used by approximately 30% of the population who can afford fee-for-service payment. The TB prevention program is operated by health centers and provincial hospital outpatient clinics in the public sector. In the private sector, there are 1090 TB-DOTS clinics, and those working in private hospitals, pulmonary specialists, and some general practitioners participate in the DOTS program. Outpatient TB-DOTS is included in the benefits package, but outpatient consultation and ongoing requirements for medication are not yet included [23]. Cost may be among the barriers in accessing TB services, although the national TB budget was 104 million US dollars in 2016 [21]. Regarding treatment outcomes and prevention, the TB treatment coverage in 2015 involved 85% of the reported and estimated incidence cases. Approximately 92% of new and relapsed cases registered in 2014 had been previously treated cases, excluding those relapsed cases (83%) registered in 2014 [22].

The use of NTP surveillance system data to report the number of TB cases in the Philippines has several limitations. Cases diagnosed and treated in health facilities outside the NTP network of providers, including private clinics and hospitals, are not included; therefore, the surveillance system underreports the total number of TB cases in the Philippines [18].

The Code of Sanitation of the Philippines (Presidential Decree No. 856) was instituted in 1975. In 1929, the Law on Reporting of Communicable Diseases was enacted, which required all individuals and health facilities to report notifiable diseases to local and national health authorities. In addition, the Act reorganized the TB Unit in the Department of Health to specify that the TB Unit have the functions of pooling all information on TB and exchanging such information with other countries. Section “Results” of the Law of Reporting of Communicable Disease states that a case of reportable or communicable disease shall include any person sick from, affected by, or attacked by a communicable disease; and that TB should be on the list of the reportable diseases.

The Law on Reporting of Communicable Diseases (Republic Act 3573) still requires all individuals and health facilities to report notifiable diseases to local and national health authorities. In 1990, the Department of Health circular No. 157 was issued, which comprised a list of reported diseases included on the reviewed list of notifiable or reportable diseases. In that circular, TB is listed as a reportable disease along with the case definitions of TB, meningitis, respiratory illnesses, and other types of communicable diseases. The 1997 revised list of notifiable diseases is the same as that of the 1990 document. However, the 2001 revised list of notifiable or reportable diseases included diseases and syndromes that had been selected because they were epidemic-prone diseases, targeted for eradication or elimination, and subject to international health regulations. TB was no longer included the list of reportable or notifiable diseases.

A recent update on the administrative Order no. 9 series (2008) includes a revised list of notifiable diseases, syndromes, and health-related events and conditions. It describes two categories of notifiable diseases: an “immediate” notifiable disease category consisting of 13 diseases and a “weekly” notifiable disease category, which includes 14 diseases. However, TB is not included in either of these categories.

The following international standards on notifiable disease reporting include: International Health Regulations [19], the Asia Pacific Strategy for Emerging Diseases [20], and the International Digest of Health Legislation (IDHL). The WHO has used the IDHL as a guide for domestic law since 1948. The IDHL includes norms and standards of legislation on communicable disease issues, comprising epidemic control measures, immunization and vaccination, notification requirements, prevention and control measures, and tests dealing specifically with HIV/AIDS. The Code of Sanitation of the Philippines notes that the Philippines recognized the [19] and that some of the provisions in the IHR may be considered part of this code.

The reporting of TB as a notifiable disease is intended to control TB through ensuring that healthcare professionals have an official obligation to inform the government concerning TB to enable it to control the disease and authorize health officials to act as necessary. However, this practice is not mandatory in the Philippines. Nine of 17 countries selected have legislation declaring TB as a notifiable disease. These countries include Australia, Canada, China, Kiribati, New Zealand, the Republic of Korea, Singapore, the United Kingdom, and Vanuatu. The other 8 countries have notification regulations in their domestic laws, but which do not specify the diseases, including TB. Examples of legislation in different countries concerning the notification of TB are presented in Table 1. Because the sample countries are mainly drawn from the Western Pacific region, our study findings are primarily applicable to countries within this region. However, given that TB is a notifiable disease in other countries such as the United Kingdom and Canada, the results of the study provide useful information in understanding international practice more broadly.

The goals of TB control are to reduce mortality, morbidity, and disease transmission until it no longer poses a threat to public health. One of the target goals of TB control is case detection. In one US study, reporting of TB cases contributed to the identification of more TB cases, which led to improved TB control. Reporting has been defined as the “obligation of health care institutions, laboratories, and health care or allied health professionals who diagnose, treat, or care for TB patients to report confirmed or suspected cases to the appropriate health agencies (CDC, 2009).” In some cases, this obligation includes notifying the appropriate agencies or authorities of the patient’s adherence or non-adherence to treatment. In the US, TB control laws have established reporting requirements even at the sub-national jurisdiction level in at least 25 different jurisdictions, based on legal research, review, and feedback provided by legal and TB practitioners [4]. Health care providers, laboratories, or others are legally required to report suspected or confirmed cases of TB, MDR-TB, or XDR-TB infection, and public health officials in state or non-state agencies are legally required to further report such information to any other entity at the appropriate local, state, or tribal levels.

Since 2012, TB has been a notifiable disease in India, which means that all cases of TB diagnosed by any means must be reported to the public health authorities following a specified format [1]. This initiative was implemented to estimate the number of TB cases in the community with greater accuracy [14]. China, a country with the second highest number of TB cases, has improved its TB estimates drastically since implementing a web-based system of mandatory case reporting in 2005 [7, 8, 24]. Other countries reviewed in this study have also enacted or revised laws concerning TB and notification requirements; thus, these countries have a current regulatory reporting system.

There is a wide-ranging consensus among many countries concerning the notification of TB. It is clear that public health legislation can facilitate more effective interventions in identifying and controlling communicable diseases. Specific public health regulations requiring the notification of TB appear to be a standard best practice norm internationally. It is likely that the Philippines would benefit from adding TB to its current list of notifiable diseases.