NATIONAL TUBERCULOSIS

PREVALENCE SURVEY 2016,

PHILIPPINES

In collaboration with:

Foundation for the Advancement Philippine Council for Health

of Clinical Epidemiology, Inc. Research and Development
NATIONAL TUBERCULOSIS
PREVALENCE SURVEY 2016,
PHILIPPINES
(Provisional report, September 5, 2017)

Foundation for the Advancement Philippine Council for Health

of Clinical Epidemiology, Inc. Research and Development

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Copyright page

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 Tuberculosis (TB) has been a longstanding health challenge in
the country. The findings from the 2016 National TB Prevalence
Survey (NTPS) indicate that it remains to be a significant public
health problem. The President and this administration through
the Department of Health is concerned, and has made the
prevention and control of TB among Filipinos a health priority!
To do this, we must step up our efforts and go beyond “business
as usual” and shift to: #businessunusual The 2017–2022
Philippine Strategic TB Elimination Plan, Phase 1 (PhilSTEP1) addresses
programmatic gaps in the TB control efforts and has boldly moved to strategies
towards TB elimination. In particular, we are adopting three bold shifts: (1) find TB
cases more aggressively across the country; (2) make TB treatment easier and more
accessible; and (3) provide financial protection for TB patients.
With these bold steps, at least 3 million TB cases in six years will be detected through
more aggressive use of chest X-ray screening, followed by diagnosis using more
sensitive and rapid tools such as Xpert MTB/RIF. We will include chest X-ray
screening as part of the TSEKAP package, targeting 50% of Filipinos, especially the
poor and high-risk groups. We will link aggressive case-finding to effective, patient-
centered treatment, with a target of more than 90% of all diagnosed TB patients. To
provide financial protection, the government intends to expand the health insurance
and social insurance coverage for all TB patients. Our aim is to reduce catastrophic
costs associated with TB to less than 10% by 2022.
To raise and sustain public awareness and better case detection, management and
notification of TB cases, we need strong support from our partners in the private sector,
civil society, and key government agencies like DepED, CHED, PIA, and DSWD. We
need the full cooperation of the private and public sectors in implementing mandatory
notification of TB, as provided in Republic Act No. 10767: Comprehensive
Tuberculosis Elimination Plan Act of 2016.
I am confident that our country will be able to surmount obstacles and turn around the
findings from the 2016 NTPS. Let us shift and shake our strategies against TB and
achieve DOH’s vision of promoting all for health towards health for all!

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CONTENTS

Contents v
List of tables viii
List of figures xii
Acknowledgments xiv
NTPS writing team 1
Abbreviations 2
Executive summary 5
1. Background 11
2. Study objectives 15
2.1. Primary objectives 15
2.2. Secondary objectives 15
3. Organizational structure 17
4. Methods 19
4.1. Survey design and coverage 19
4.2. Study population 20
4.3. Field survey proper 20
4.4. Chest X-ray 22
4.4.1. Chest X-ray procedure 22
4.4.2. Chest X-ray reading by the field team leader 23
4.4.3. Chest X-ray reading by the off-site radiologist 23
4.4.4. Chest X-ray reading by central radiologist 24
4.5. House-to-house interviews 25
4.6. Sputum collection in the field 25
4.7. Laboratory procedures 25
4.7.1. Fluorescence microscopy 25
4.7.2. Mycobacterial culture 26
4.7.3. Xpert MTB/RIF test 27
4.8. The Diagnostic and Medical Panel 27
4.9. Quality management procedures 30
4.10. Data management and analysis 31
4.10.1. Data management flow 31
4.11. Statistical analysis 33
4.11.1. Survey measures 33

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 4.12. Statistical analysis to estimate the prevalence of BCTB 33
4.12.1. Describing survey data 33
4.12.2. Tests of significance 34
4.12.3. Multivariable analysis for determining association of
possible risk factors for TB 34
4.12.4. Determining inter-observer agreement between chest X-
ray readings 34
4.13. Ethical considerations 35
5. Results 36
5.1. Census of clusters and survey-eligible population 36
5.1.1. Household profile in the clusters surveyed 38
5.1.2. Census and survey population profile 39
5.1.3. Symptom screening 46
5.1.4. Chest X-ray screening 52
5.1.5. Sputum eligibility by screening symptoms and chest X-ray 57
5.1.6. Sputum collection 60
5.2. Laboratory results 62
5.2.1. Overall laboratory results 62
5.2.2. DSSM results 65
5.2.3. Xpert MTB/RIF results 66
5.2.4. Culture results 69
5.2.5. Laboratory quality assurance 73
5.3. Bacteriologically confirmed PTB cases 75
5.3.1. TB case classification by the diagnostic medical panel 75
5.3.2. Symptoms and chest X-ray findings among survey cases 77
5.3.3. Screening symptoms eligibility and current TB treatment
among survey cases 81
5.3.4. History of treatment of survey TB cases 82
5.3.5. General characteristics of the bacteriologically confirmed
PTB survey cases 84
5.3.6. Comparison of households with and without TB cases 88
5.3.7. Health seeking behavior of survey participants and survey
TB cases who reported being currently treated for TB 89
5.4. TB prevalence estimates 92
5.5. Comparison of 2007 and 2016 NTPS 94
5.6. Health care-seeking behavior 103

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 5.6.1. Health care-seeking behavior among participants with self-
reported screening symptoms of TB 103
5.6.2. Health care-seeking behavior among survey TB cases 109
5.6.3. Health care-seeking behavior among participants with
history of TB 110
5.7. Risk factors for TB 114
6. Discussion 118
6.1. TB prevalence estimates 118
6.2. Reasons for the high TB burden 119
6.3. TB screening and diagnostic tools 125
6.4. Limitations of the study 127
6.4.1. Low participation rate 128
6.4.2. Inter-observer variabilities in CXR readings 129
6.4.3. Conditions affecting laboratory results 130
6.4.4. Assessment of diabetes mellitus and HIV as risk factors for
TB 130
6.4.5. Non-inclusion of children and other groups 131
6.4.6. Recall bias and stigma 131
7. Conclusion and Recommendations 132
7.1. Main findings 132
7.1.1. TB burden 132
7.1.2. Other key findings 133
7.2. Program implications and recommendations 134
7.2.1. Short-term recommendations 135
7.2.2. Long-term recommendations 137
7.3. Proposed research studies 138
References 140

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LIST OF TABLES

Table 1. Comparison of strategies of National Strategic Plan to Control

TB and the 2010–2016 Philippine Plan of Action to Control TB
(PhilPACT) 12
Table 2. National reporting scale for AFB microscopy 26
Table 3. Standard reporting scheme for growth in solid culture 26
Table 4. Case definition algorithm used by the Diagnostic and Medical
Panel 28
Table 5. Distribution of cluster and households 38
Table 6. Household participation by stratum and geographical location 39
Table 7. Survey population by eligibility criteria 41
Table 8. Survey household population by household characteristics and
household participation 42
Table 9. Distribution of eligible population by demographic characteristics
and participation in the survey 44
Table 10. Socio-demographic characteristics of survey participants by
stratum 48
Table 11. Socio-demographic characteristics of survey participants who
had screening symptoms 49
Table 12. Socio-demographic characteristics of survey participants who
had screening symptoms 50
Table 13. Occupation of survey participants who had screening
symptoms 51
Table 14. Distribution of survey participants by chest X-ray status and
socio-demographic characteristics 53
Table 15. Reasons for not having a chest X-ray taken 53
Table 16. Distribution of participants without screening symptoms and
without a chest X-ray, by sex and age 54
Table 17. Distribution of chest X-ray reading by the field team leaders
and/or off-site radiologists, by demographic characteristics 55
Table 18. Inter-observer agreements for chest X-ray readings by different
sets of readers 56

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Table 19. Results of screening based on symptoms and field chest X-ray
results 58
Table 20. Distribution of non-specific symptoms among survey
participants positively screened for TB based on field chest X-
ray findings only 58
Table 21. Distribution of non-specific symptoms among sputum-eligible
participants without screening symptoms and without chest X-
ray 59
Table 22. Distribution of non-specific symptoms among participants who
were not sputum-eligible 60
Table 23. Distribution of sputum-eligible participants and sputum
collection status by sex and age group 60
Table 24. Distribution of sputum-eligible participants by stratum and
sputum collection status 61
Table 25. Availability of sputum specimens from sputum-eligible survey
participants 61
Table 26. Distribution of laboratory results by TB laboratory 64
Table 27. DSSM results of spot and morning specimens 65
Table 28. Sensitivity and specificity of DSSM LED-FM for M. tuberculosis
using combined Xpert MTB/RIF and culture results as gold
standard 66
Table 29. Comparison of Xpert MTB/RIF and DSSM results 67
Table 30. Comparison of Xpert MTB/RIF vs. culture results among
smear-positive specimens 67
Table 31. Comparison of Xpert vs. culture results among smear-negative 68
Table 32. Comparison of Xpert MTB/RIF vs. culture results, regardless of
DSSM results, 2016 NTPS 68
Table 33. Distribution of mycobacterial culture results from spot and
morning specimens 70
Table 34. Culture results by colony count 71
Table 35. Comparison of culture and DSSM results 71
Table 36. Comparison of rifampicin resistance detected by Xpert
MTB/RIF and DST results 72

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Table 37. Distribution of drug susceptibility test results among those with
positive TB culture results 73
Table 38. Performance quality indicators for the six participating TB
laboratories 74
Table 39. Case classification of 470 survey participants with
bacteriologically confirmed results 76
Table 40. Classification of survey TB cases 76
Table 41. Distribution of symptoms of the sputum-eligible population
according to self-reported screening symptoms 77
Table 42. Distribution of smear-positive and bacteriologically confirmed
TB cases according to symptoms screening and chest X-ray
results (field reading) 78
Table 43. Sensitivity and specificity of screening symptoms using the
final survey case classification as the gold standard 78
Table 44. Sensitivity and specificity of field reading of chest X-rays using
the final survey case classification as the gold standard 79
Table 45. Distribution of symptoms and chest X-ray results (central
reading) of survey cases 80
Table 46. Chest X-ray results of the survey TB cases 81
Table 47. Distribution of bacteriologically confirmed PTB survey cases
according to presence of screening symptoms and history of
TB treatment 82
Table 48. Association of TB treatment history with rifampicin resistance
on Xpert MTB/RIF among survey TB cases 83
Table 49. Survey case classification by treatment history 84
Table 50. Socio-demographic characteristics of survey TB cases
compared to those without TB 85
Table 51. Socio-demographic characteristics of survey TB cases
compared to those without TB 87
Table 52. Risk factors for survey cases compared to non-cases 88
Table 53. Socio-demographic characteristics of households with and
without TB cases 89
Table 54. Health-seeking behavior of survey participants cases who
reported being on TB treatment at the time of the survey 90

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Table 55. Estimated prevalence of smear positive and bacteriologically
confirmed PTB among individuals aged ≥15 years, age group
and stratum 92
Table 56. Differences in the survey methods of the 2007 and 2016
prevalence surveys 94
Table 57. Population in the clusters of 2007 and 2016 NTPS according to
the 2007 and 2015 census 100
Table 58. Distribution of TB cases in the 2007 and 2016 NTPS using
restricted parameters for comparability 101
Table 59. Health care-seeking patterns of survey participants with
screening symptoms 106
Table 60. Reasons for self-medicating or not taking action among
participants with TB screening symptoms, by sex 107
Table 61. Reasons for not seeking formal medical consultation among
participants with TB screening symptoms, by sex 109
Table 62. Distribution of health care-seeking behavior of symptomatic
survey TB cases compared to other survey participants who
had screening symptoms 110
Table 63. TB care provided to survey participants with previous TB
treatment in 2011 onwards, by sex 113
Table 64. Adherence to TB treatment and reasons for stopping
medications among survey participants with previous TB
treatment in 2011 onwards, by sex 114
Table 65. Risk factors for pulmonary tuberculosis among survey
participants 116

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LIST OF FIGURES

Figure 1. 2016 NTPS organizational structure 18

Figure 2. Figure of the Philippines with clusters marked 20
Figure 3. Physical set-up and flow at the survey site 21
Figure 4. NTPS data management flow 31
Figure 5. 2016 NTPS website 32
Figure 6. Flow diagram of 2016 NTPS, Philippines based on 106 clusters 37
Figure 7. Age and sex pyramid of the 2016 NTPS census and the 2010
Philippine census 40
Figure 8. Age and sex pyramid for survey census and the survey-eligible
population 41
Figure 9. Age and sex pyramid for survey-eligible individuals vs. actual
participants 45
Figure 10. Participation rate by sex and age group 45
Figure 11. Flow diagram of DSSM, Xpert MTB/RIF, and culture results 63
Figure 12. Distribution of prevalence by cluster 85
Figure 13. Age and sex distribution of the 466 survey cases 86
Figure 14. Distribution of survey participants and survey TB cases who
were currently under TB treatment 91
Figure 15. Prevalence of smear positive and bacteriologically confirmed
TB cases by age groups 93
Figure 16. Prevalence of Xpert-positive and culture-positive TB by age
groups 93
Figure 17. Stratum 1: Location of the clusters in the National Capital
Region, Region 3, and Region 4A for the 2007 and 2016
surveys 96
Figure 18. Stratum 2: Location of the clusters in the rest of Luzon for the
2007 and 2016 surveys 97
Figure 19. Stratum 3: Location of the clusters in Visayas for the 2007 and
2016 surveys 98
Figure 20. Stratum 4: Location of the clusters in Mindanao for the 2007
and 2016 surveys 99

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Figure 21. Trends in the 2007 and 2016 NTPS in terms of culture-positive
TB prevalence and smear-positive TB prevalence 102
Figure 22. Distribution of the estimates prevalence rates for culture-
positive TB based on the 2007 and 2016 NTPS 102
Figure 23. Health care-seeking patterns of survey participants with
screening symptoms 104
Figure 24. Multiple factors leading to the high TB burden 119
Figure 25. Comparison of health-seeking behavior pattern described in
the national TB prevalence surveys in 2007 and 2016 121
Figure 26. Incidence and case notification rates in the Philippines, 2000–
2015 124
Figure 27. Ratio of prevalence to case notification 124
Figure 28. Scatterplot of weighted cluster prevalence and participation
rates 129

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Acknowledgments

Survey Steering Committee

Usec. Gerardo Bayugo, former Usec. Vicente Belizario, Jr., Dr. Mario Baquilod, Dr.
Rosalind Vianzon, Dr. Irma Asuncion, Dr. Kenneth Ronquillo, Dr. Socorro Lupisan, Dr.
Lilibeth David, Dr. Regina Berba, Dr. Jaime Montoya, Dr Jose Hesron Morfe, Dr.
Kathryn Roa, Mr. Eric Camacho, Dr. Nobuyuki Nishikiori.

Survey Technical Working Group

Dr. Anna Marie Celina Garfin, Dr. Ma. Cecilia Ama, Ms. Elizabeth Cajigas, Mr. Paul
Ernest De Leon, Dr. Mariquita Mantala, Mr. Reno Carter Nalda, Ms. Amelia Sarmiento,
Dr. Agnes Segarra, Ms. Ma. Rosella Taguiang, Dr. Carlos Tan Jr., Dr. Rajendra
Yadav.

Survey DOH and PCHRD Joint Secretariat

Mr. Jude Daval-Santos, Ms. Jacqueline Gabiola, Ms. Donna Mae Gaviola, Dr.
Francisco Ogsimer Jr., Ms. Maricel Trono, Ms. Clarissa Reyes, Ms. Arianne Zamora.

WHO Technical Assistance Team

Dr. Bintari Dwihardiani, Dr. Julia Ershova, Dr. Philippe Glaziou, Dr. Yasunori Ichimura,
Dr. Irwin Law, Ms. Hiroko Matsumoto, Dr. Ikushi Onozaki, Mr. Tetsuhiro Sugamoto,
Dr. Marina Tadolini, Dr. Mukund Uplekar.

Partners
Organizations: World Health Organization; United States Agency for International
Development; The Global Fund to Fight AIDS, Tuberculosis and Malaria; Philippine
Coalition against TB; Philippine Business for Social Progress, University of the
Philippines Manila College of Medicine and Philippine General Hospital, UPM National
Institutes of Health
Special thanks to: all DOH Regional Health Offices, Provincial Health Offices
especially NTP Coordinators, local government units of the participating clusters,
city/municipal health officers and staff, barangay health workers, and community
volunteers.
PBSP: Mr. Armando Castillo, Mr. Ermon Bryan Fernandez.
MinXray: Mr. Michael Cairnie, Mr. Ed Dubbs, Mr. Joel Koplos.
Other partners: Asec. Agnette Peralta, Dr. Marita Reyes, Mr. Renante Bahala, Dr.
Salvacion Gatchalian, Mr. Mike Gomez, Dr. Carlo Panelo, Mr. Mubarak Pangandaman

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Project Implementation Team
Consortium: The Foundation for the Advancement of Clinical Epidemiology, Inc.,
Foundation for the Control of Infectious Diseases, Inc., Philippine College of
Radiology.
Participating laboratories: National TB Reference Laboratory, UP-PGH Medical
Research Laboratory, Regional II TB Reference Laboratory, Cebu TB Reference
Laboratory, Northern Mindanao TB Reference Laboratory, Davao TB Reference
Laboratory.

Project Coordination Committee

Dr. Mary Ann Lansang (Project Leader), Dr. Marissa Alejandria, Dr. Noel Juban,
Dr. Jacinto Blas Mantaring III, Dr. Myrna Mendoza, Dr. Amelia Fernandez, Prof.
Maria Lourdes Amarillo, Ms. Concepcion Ang, Dr. Joseph Adrian Buensalido, Dr.
Johanna Patricia Cañal, Prof. Nina Castillo-Carandang, Prof. Cynthia Cordero, Dr.
Mary Ann Ladia, Dr. Hilton Lam, Dr. Jodor Lim, Ms. Cynthia Miguel (†), Dr. Maria
Sonia Salamat, Prof. Olivia Sison.

Administration and Finance Unit

Ms. Danielle Joyce Abarico, Ms. Danna Lee Acosta, Ms. Daisy Agcaoili, Ms.
Rachel Aranda, Ms. Sylvia Cruz, Ms. Imelda de Leon, Ms. Reinelle Ann de Leon,
Ms. Catherine Espenocilla, Ms. Abigael Estacio, Mr. Mario Lasquite Jr., Ms. Mary
Francia Rose Llanto, Mr. Rammie Val Lucena, Mr. Joel Quiñones, Mr. Alenn Kim
Pee San Jose, Ms. Jennifer Serrano, Ms. Maria Pamela Tagle.

Central Technical Affairs Units

Data Management Unit: Mr Paul Adriel de Leon, Mr. Paul Jeshimon de Leon, Ms.
Sarah Jane Fabito, Mr. Patrocinio Leonador, Mr. John Paschal Lucas, Mr. Alfredo
Manzano Jr., Ms. Michelle Mayores, Ms. Joyce Ann Monakil, Ms. Kerry Joana
Ong, Ms. Kathleen Salvacion, Ms. Herrje Soreda, Ms. Mary Gil Tarroc, Mr.
Sulpicio Yangao Jr.
Diagnostic and Medical Panel: Ms. Richell Ador, Dr. Jubert Benedicto, Dr. Ian
Theodore Cabaluna, Dr. Christopher de los Santos, Dr. Christian Francisco, Dr.
Christine Peñalosa, Dr. Camilo Roa, Dr. Mediadora Saniel, Dr. John Carlos
Valencia.
Laboratory/TB Diagnostics Team: Ms. Irene Abejuela, Ms. Jenny Alabado, Ms.
Manilyn Allavun, Mr. Joseph Mark Anque, Ms. Jhya Aurelio, Dr. Ramon Basilio,
Mr. Howell Henrian Bayona, Ms. Cresilda Cases, Ms. Renee Fleur Clutario, Mr.
Rodrigo Covacha, Ms. Lorianne Marie Cunanan, Ms. Sonia Dapitanon, Ms.
Christine Mae de la Cruz, Mr. Eleazar Ed Duarte, Ms. Myra Riccil Estose, Ms.
Anne Lucette Flores, Mr. Leodegario Halog, Mr. Jordan Kintanar, Mr. Philip Patrick
Lee, Ms. Krissha Marfil, Ms. Rosamer Ann Plan, Ms. Sittie Najeha Pumbaya, Mr.
Lorenzo Reyes, Ms. Perla Sanchez, Ms. Jeanelyn Taguinod, Ms. Ma. Angelica
Tumbali, Mr. Titus Ian Valerio, Ms. Alena Faye Villanueva.
Radiology Team: Dr. Ramon Martin Bañez, Dr. Maria Teresa Julieta Benedicto,
Dr. Julian Cañero, Dr. Aileen Desipeda, Dr. Ginoo Karlo Angelo Galvez-Tan, Dr.

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Timothy Joseph Orillaza, Dr. Rene Reyes, Dr. Danilo Sacdalan, Dr. Raquel
Sacdalan, Dr. Mario Sarmenta, Dr. Manuel Felipe Tuason, Dr. Cynthia Joy Maxino
Uy.

Field Survey Unit

Field Team Leaders: Dr. Luis Anos, Dr. Jose Rene Bagani Cruz, Dr. Anjo Benedict
Fabellon, Dr. Nori Jane Galagar, Dr. Allison Noel, Dr. Rodelia Pascua, Dr. Aser
Sisona.
Other field staff: Mr. Jayson Ablir, Ms. Lanie Alcañeses, Mr. Rizal Alonzo, Ms.
Leoncia Amat, Mr. Nathaniel Badiang, Mr. Robert Thomas Balita, Mr. Julius
Nhicko Bartolata, Ms. Blaise Bautista, Mr. Raldy Benavente, Mr. Justin Dale Bituin,
Mr. David Paul Bolen, Ms. Bernadette Jinky Cabillar, Mr. Jason Caleze, Ms
Loraine Xian Zenn Claver, Ms. Susan Consigo, Mr. Dexter John Cruz, Mr. Jaybee
De Mesa, Ms. Cindy Dela Cruz, Ms. Stephanie Dimayuga, Mr. Michael Ronald
Dorado, Mr. Erik Dumayas, Ms. Mary Grace Fajardo, Ms. Rendal Sarah Grace
Garingo, Ms. Precious Germar, Ms. Norjana Lago, Ms. Nor-En Lambac, Ms.
Rachel Longalong, Ms. Lorna Mabilangan, Ms. Benella Madarang, Mr. John Mark
Marquez, Ms. Shirley Mendros, Ms. Mielyn Mercan, Ms. Almira Noh, Mr. Mark
Paul Ondillo, Ms. April Joy Paloma, Mr. Reinnere Palomaria, Ms. Lady Lyn Robles,
Mr. Garrie Kris Rodriguez, Ms. Louise Ann Sanchez, Mr. Jairus Santillan, Ms.
Maria Lourdes Ugay, Mr. Jonell Joy Vales, Mr. Marlon Villaver, Ms. Melanie
Zamora, Ms. Nelsa Zaragoza.

Quality Management Unit

Mr. Marc Agnew Cajucom, Dr. Adrian Ronald Espino, Dr. Ma. Celina Cephyr
Gonzalez, Dr. Jan Alexeis Lacuata, Dr. Oliver Lim, Ms. Mikarla Lubat, Ms. Felisa
Pa-alan, Dr. James Salisi.

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 NTPS writing team

Mary Ann Lansang

Marissa Alejandria
Maria Lourdes Amarillo
Concepcion Ang
Howell Henrian Bayona
Joseph Adrian Buensalido
Ian Theodore Cabaluna
Johanna Patricia Cañal
Nina Castillo-Carandang
Cynthia Cordero
Jose Rene Bagani Cruz
Paul Jeshimon de Leon
Christopher de los Santos
Sarah Jane Fabito
Noel Juban
Mary Ann Ladia
Mikarla Lubat
Jacinto Blas Mantaring III
Myrna Mendoza
Maria Sonia Salamat
James Salisi
Olivia Sison
Herrje Soreda

Special thanks to:

Anna Marie Celina Garfin
Irwin Law
Mariquita Mantala
Ikushi Onozaki
Marina Tadolini
Rajendra Yadav

1
Abbreviations

4Ps Pantawid Pamilyang Pilipino Program

AFB Acid-fast bacilli

ARMM Autonomous Region of Muslim Mindanao

BCTB Bacteriologically confirmed tuberculosis

BSC Biological safety cabinet

CAPI Computer-assisted personal interviewing

CTRL Cebu TB Reference Laboratory

DOH Department of Health

DOST Department of Science and Technology

DOTS Directly Observed Treatment, Short Course

DSSM Direct sputum smear microscopy

DST Drug susceptibility testing

DTRL Davao TB Reference Laboratory

Execom Executive committee

FACE Inc. Foundation for the Advancement of Clinical Epidemiology,

Inc.

FCID Inc. Foundation for the Control of Infectious Diseases Inc.

HUC Highly urbanized cities

IPW Inverse probability weighting

LED Light-emitting diode

LPA Line Probe Assay

MDG Millennium Development Goals

MDR-TB Multi-drug resistant Tuberculosis

MI Multiple imputation

MRL - PGH Medical Research Laboratory – Philippine General Hospital

2
MTB M. tuberculosis

NCR National Capital Region

NEC National Ethics Committee

NMTRL Northern Mindanao TB Reference Laboratory

NSO National Statistics Office

NTM Nontuberculous mycobacteria

NTP National Tuberculosis Control Program

NTPS National Tuberculosis Prevalence Survey

NTRL National TB Reference Laboratory

OSL Optically Stimulated Luminescence

PBSP Philippine Business for Social Progress

PCC Probe check control

PCHRD Philippine Council for Health Research and Development

PhilPACT Philippine Plan of Action to Control TB

PhilSTEP1 PhilPACT strategic TB elimination plan phase 1

PIN Personal identification number

PMDT Programmatic management of drug-resistant TB

PPS Population proportional to size

PSA Philippine Statistics Authority

PSU Primary sampling unit

PTB Pulmonary tuberculosis

QM Quality management

R2TRL Region 2 TB Reference Laboratory

SC Steering Committee, NTPS

SDG Sustainable Development Goals

SOP Standard Operating Procedures

3
SPC Sample processing control

SSU Secondary sampling unit

TB Tuberculosis

TRL TB Reference Laboratory

TWG Technical Working Group, NTPS

UPM University of the Philippines Manila

USAID United States Agency for International Development

WHO World Health Organization

WHO/GTB/TME WHO Global TB Task Force on TB Impact Measurement

4
EXECUTIVE SUMMARY

Many developing countries worldwide are witnessing a rise in the burden of

tuberculosis (TB)—more than what had been previously estimated. It is important for
the Philippines to know what the true TB situation is, given that 10 years have passed
since the 3rd national TB prevalence survey (NTPS) in 2007. As the Philippines
transitions from the 2010─2016 Philippine Action Plan to Control TB (PhilPACT) and
segues into Phase 1 of the 2017─2022 strategic plan to eliminate TB (PhilSTEP1), it
is time to take stock, determine what has been achieved, and identify the gaps and
challenges ahead.

The DOH, in cooperation with the Philippine Council for Health Research and
Development and the Foundation for the Advancement of Clinical Epidemiology, Inc.
(FACE, Inc.), conducted a nationwide, population-based, cross-sectional TB
prevalence survey from March–December 2016. This involved a nationally
representative sample (selected by multi-stage cluster sampling) of individuals aged
≥15 years residing in clusters from four strata: stratum 1—National Capital Region,
Region 3 and 4A; stratum 2—the rest of Luzon; stratum 3—Visayas; and stratum 4—
Mindanao. The estimated sample size requirement was 51,000 from 102 clusters, with
6 additional clusters added to round off allocations to strata and to factor in drop-outs
due to security reasons.

Survey participants were screened by symptom questionnaire and digital chest X-ray
imaging. Two sputum samples were collected from those with screening symptoms
(cough ≥2 weeks and/or hemoptysis) and/or a chest X-ray suspicious for TB. Direct
sputum smear microscopy using light-emitting diode fluorescence microscopy and
solid culture for M. tuberculosis (MTB) were done. An added key feature of the 2016
NTPS—not available during the 1983, 1997, and 2007 national surveys—was the use
of Xpert MTB/RIF, a novel molecular test incorporating DNA amplification to enhance
detection of MTB and rifampicin resistance. A bacteriologically confirmed pulmonary
TB case was defined as a participant with sputum samples positive on culture for MTB
and/or Xpert MTB/RIF.

Out of a total survey census population of 89,663 individuals, 61,466 individuals were
declared eligible to participate in the survey from 106 clusters, based on age (≥15
years old) and residency criteria (having spent at least the last two weeks in the cluster

5
or slept in the household >50% of the time in the past month). Of the 61,466 eligible
individuals, 46,689 (76%) participated in the survey. A total of 18,597 individuals
(39.8%) were declared eligible for sputum sample collection, out of whom 16,242
(87.3%) provided at least one sputum sample. Samples were tested with smear
microscopy, MTB culture, and Xpert MTB/RIF.

There were 466 bacteriologically confirmed pulmonary TB cases, 173 (37.1%) of

which were smear-positive. Chest X-ray screening alone identified 98.4% cases (430
out of 437 available chest X-rays) compared with 32.2% (150 out of 466) identified by
symptom screening alone. Of the 466 cases, 34.1% (159) were positive by MTB
culture and Xpert MTB/RIF, 14.8% (69) by MTB culture alone, and 51.1% (238) by
Xpert MTB/RIF alone.

Based on the prevalence survey findings, the estimated prevalence of smear-positive

and bacteriologically confirmed pulmonary TB in those ≥15 years was 434 per 100,000
(95% C.I. 350─518) and 1,159 per 100,000 (95% C.I. 1,016─1,301), respectively.
Prevalence significantly increased with age and was higher in males (1,713 per
100,000, 95% CI 1,482─1,943) compared to females (627 per 100,000, 95% CI
516─739).

Key findings of the 2016 NTPS were:

 The burden of TB remains high among Filipino adults, and is higher than
previously estimated.

 Around 1 million Filipinos are expected to have tuberculosis, and may or

may not even know it.
 Around 760,000 Filipinos aged ≥15 years are estimated to have pulmonary
TB.
 Based on culture-positive pulmonary TB cases identified in the 2016 NTPS,
there is no evidence of a decline in pulmonary TB prevalence rates
compared to the 2007 NTPS.
 Several factors have been found significantly associated with the risk of
having pulmonary TB: previous TB treatment, older age group, being male,
diabetes mellitus, smoking, indicators of poverty, and urban dwellers.

6
 Current TB program modes of screening by symptoms and diagnosing by
sputum microscopy are not sufficient for early diagnosis of patients with TB.

 During active case finding scenarios, screening for TB cases using

symptoms alone would have missed one-third to two-thirds of
bacteriologically confirmed pulmonary TB cases.
 Two-thirds of bacteriologically confirmed cases were smear-negative.
Under field conditions, Xpert MTB/RIF detected 1.7 times more TB cases
than culture for M. tuberculosis.

 Under-reporting of TB cases to the national TB registry is likely.

 The prevalence to notification ratio for smear-positive pulmonary TB across

all ages was 3.1, with the highest ratios found in the age groups 15─24 years
(4.2) and 45─54 years (3.3) and among men (3.3).
 One-half of those who claimed to be on anti-TB treatment at the time of the
survey were not found in the national TB registry. Of those found in the TB
registry, 94% cases were reported by public providers, suggesting
insufficient notification and reporting from private providers.

 Health care-seeking behavior for symptoms suggestive of TB remains

inappropriate.

 Only 6% of survey participants had cough of ≥2 weeks, with or without

hemoptysis, at the time of the survey. However, 41% of those with these
symptoms suggestive of PTB did not take any action, while 40% self-
medicated. Only 19% consulted a healthcare worker, mostly in the public
sector (67%).
 The perceived trivial nature of symptoms and costs related to work-day lost,
travel, and drugs were the primary reasons for not consulting a healthcare
provider.

The reasons for the high TB prevalence are probably multi-factorial: supply-side and
health systems weaknesses, demand-side factors like health-seeking behavior, and
associated health problems such as smoking and diabetes mellitus. Most importantly,
persistence of poverty and worsening inequities continue to fuel the spread of TB and
to undermine control efforts.

7
As such, eliminating TB must be a national and multi-sectoral priority. To reach the
TB-free target within the Sustainable Development Goals will require urgent and
sustained actions at the national and local levels. PhilSTEP1 for 2017─2022 aims to
achieve its ambitious goals to reduce TB incidence by 90% and mortality by 95% in
2035. Considering that the 2016 NTPS has contributed important information towards
a new baseline against which PhilSTEP1 strategies will be measured, a major rethink
of actions at the national and local levels is required.

Short-term recommendations:

1. Do systematic screening for TB among high-risk and vulnerable groups. The

prime imperative is to develop effective strategies to find the missing TB cases and
draw them in early as partners in the cascade of care. Priority should be given to those
most at risk: men, older age groups, the poor, dwellers in urban slums, smokers, those
previously treated for TB, and those with diabetes mellitus. There should also be
improved contact tracing and prophylactic treatment, especially among the children
and other vulnerable individuals in the households of TB cases. Without attention to
early case identification and treatment and contacts screening, the transmission cycle
of TB is perpetuated and TB is unlikely to be eliminated.

2. The tools to find the missing cases must be sharpened and enhanced. Chest
X-ray screening among identified high-risk groups will enhance the yield of traditional
screening methods. For diagnosis, scale up the use of rapid and accurate diagnostic
tests like Xpert MTB/RIF in presumptive TB cases as first line diagnostic tool to identify
TB cases and detect rifampicin resistance. While culture for MTB is still the gold
standard for TB diagnosis and is required for DST, the feasibility, rapidity, robustness,
and accuracy of Xpert MTB/RIF can contribute to the reduction of pre-treatment loss
to follow-up, allow timely commencement of treatment, almost triple the TB cases
found in comparison to smear microscopy, and identify MDR-TB cases early.

8
3. Develop innovative behavioral interventions and enablers to improve health
care seeking and adherence to treatment. Low risk perception, poor knowledge of
symptoms suggestive of TB, low trust in the health system, and low treatment
adherence can be addressed through innovative behavior change communications
coursed through motivated community-based and local change agents. Enablers to
overcome external barriers such as costs, distance, and work-days lost should be
explored, e.g., incentives for positive behavior among the poor, “walk-in” stations with
flexible hours in communities and at work, and social contracts with community-based
organizations for improved outreach.

4. Reinvigorate and transform public-private-mix (PPM) partnerships. Existing

PPM partnerships should be reassessed to determine what has worked and improve
on what has not worked. Low notification of TB cases managed by private providers
must be addressed by the development of user-friendly methods for reporting to the
TB registry, considering the creation of social contracts for up-scaling case detection
and care services, and exploring approaches to overcoming barriers such as stigma
and lack of confidence in the public sector. Engage professional medical and
paramedical societies to ensure effective implementation of the provision on
mandatory notification of TB cases, as stated in Republic Act No. 10767.

5. Strengthen the collaboration between the National TB Control Program and

other health programs. A fully integrated TB service can maximize the identification
of presumptive TB, enhance case-finding, and foster integrated patient-centered
care. Examples where strengthened collaboration will be synergistic are: HIV-TB
testing and treatment, diabetes clinics, healthy lungs and smoking cessation
programs.

Long-term recommendations:

Given the magnitude of the current TB burden, the level of effort required to eliminate
TB requires significant escalation. The poor and disadvantaged require adequate
social protection strategies and PhilHealth TB benefit packages to reduce catastrophic
costs associated with TB, especially MDR-TB. More vigorous advocacy is needed to
increase local, national, and international investments to address the huge TB burden

9
in the Philippines. Local, national, and international investments must be increased to
support the massive health systems requirements to eliminate TB: increased health
human resources, efficient logistics and supply management, and integrated TB
information systems that cover both public and private sectors.

At the most fundamental level, eliminating TB will require more comprehensive and
sustained poverty alleviation efforts and multi-sectoral partnerships at the national and
local levels.

10
1. BACKGROUND

For decades, the Philippines has suffered enormously from the health and
socioeconomic consequences of tuberculosis (TB). TB remains the eighth leading
cause of mortality in the country [DOH 2017]. The 2016 Global TB Report of the World
Health Organization (WHO) estimated that mortality from TB (excluding HIV and TB
co-infection) was 13/100,000 and incidence was 322/100,000 for the year 2015. The
number of MDR-TB/rifampicin-resistant TB cases among all notified pulmonary TB
cases was estimated at 15,000 [WHO 2016a]. Although HIV prevalence is less than
1%, its increasing trend among at-risk populations is expected to worsen the current
TB burden.

Given the changing epidemiology of health and its social determinants in the country
and the vigorous efforts to control TB over the past decade, the National TB Control
Program (NTP) of the Department of Health (DOH) requires accurate and updated
information on the TB burden, and, perhaps more importantly, the direction in which
TB epidemiology is changing, that is: Are current control efforts leading to reductions
in burden? TB prevalence surveys are an effective tool to monitor the impact of TB
control, especially in the context of international commitments such as the Sustainable
Development Goal (SDG) Target 3.3 and the End TB Strategy. The result of a series
of high-quality prevalence surveys have shown the impact of national and international
investments in TB control [Wang et al. 2014; Mao et al. 2014]. In the Philippines three
national prevalence surveys were carried out in 1981–83, 1997, and 2007 [National
Institute of Tuberculosis Philippines 1984; Tropical Disease Foundation Inc. and DOH
1997; TDR and DOH 2008]. The most recent survey in 2007 showed that TB was still
a major public health problem in the Philippines, with a prevalence of smear-positive
TB and bacteriologically-confirmed TB of 2.6/1,000 and 6.6/1,000 among those aged
10 years or more, respectively. However, between 1997 and 2007, a 31% reduction
in bacteriologically-positive TB (BCTB) prevalence and 27% reduction of smear-
positive TB prevalence was observed [Tupasi et al. 2009]. The accelerated reductions
compared with those before 1997 were attributed mainly to the Directly Observed
Treatment, Short course (DOTS) program that was implemented and rolled out in the
late 1990s and early 2000s, facilitated by strategic public-private partnership.

11
The DOH implemented two national plans to control TB in the last decade: National
Strategic Plan to Control TB (2006─2010) and 2010─2016 Philippine Plan of Action to
Control TB (2010─2016 PhilPACT). The goal to halve the TB deaths and illnesses in
2015 compared to 1990 was achieved ahead of schedule in 2012 [WHO 2014]. The
strategies in both plans, as outlined in Table 1, contributed to this achievement.
However, challenges remain, including sustaining support to maintain and increase
resources (funding and human resources); ensuring cure for all TB patients; shortfalls
in engaging with stakeholders such as the community, pharmacies, and the private
sector; addressing barriers to care; and going to the last mile in contact tracing,
infection control, risk factor management and engaging vulnerable groups [DOH,
2016].

Table 1. Comparison of strategies of National Strategic Plan to Control TB

and the 2010–2016 Philippine Plan of Action to Control TB
(PhilPACT)

National Strategic Plan to Control TB Philippine Plan of Action to Control

(2006─2010) TB (2010─2016 PhilPACT)
1. Ensure high political support for TB 1. Localize implementation of TB control
control as a priority of the national
health plan and among the local
government units
2. Improve capabilities of a critical mass of 2. Monitor health system performance
DOTS workers, both public and private,
to sustain quality implementation of
DOTS services
3. Strengthen the implementation of DOTS 3. Engage both public and private health
certification and accreditation care providers
4. Maintain the support to key 4. Promote and strengthen positive
management functions, particularly behavior of communities
5. Scale up and enhance public-private 5. Address MDR-TB, TB/HIV, and needs
mix DOTS units in strategic sites of vulnerable populations
6. Strengthen Public-to-Public 6. Regulate and make available quality
collaboration between public hospital TB diagnostic tests and drugs
and health centers to increase access
to and improve efficiency of DOTS
services
7. Support the existing DOTS (+) initiatives 7. Certify and accredit TB care providers
and institutionalize these in the public
sector
8. Strengthen the integration of TB/HIV in 8. Secure adequate funding and
accordance to the country’s disease improve allocation and efficiency of
scenario fund utilization
Source: DOH, 2013; DOH, 2016

12
The 2016 Joint Program Review of the 2010─2016 PhilPACT showed that the
Philippines met the 2015 targets under the Millennium Development Goals (MDG) and
Stop TB Partnership [DOH 2017]. Both case detection rate and treatment success rate
are more than 90% for drug sensitive TB cases; however, case finding and case
holding are low for drug-resistant TB cases. While every effort is made to improve
coverage and quality of TB notification, surveillance data to measure TB burden and
its trend, there is a considerable range of uncertainty around these figures.

Generally, after a survey, the revised prevalence estimates are higher than previously
calculated especially in Southeast Asian countries [Onozaki et al. 2015]. Prevalence
data in the Philippines have not been updated since 2007 and routinely reported data
were the main basis for the program review. Hence the NTP commissioned the fourth
national TB prevalence survey (NTPS) to provide the program with updated and more
accurate information on the current TB burden, which can also serve as baseline
information for strategic planning of TB elimination in the country. The NTPS also
provides baseline data for targets of the SDG and the End TB Strategy.

After completion of the 2010─2016 PhilPACT, a strategic TB elimination plan phase 1

for 2017–2022 (PhilSTEP1) has been formulated, based on: (1) Republic Act 10767
or the Comprehensive TB Elimination Plan Act of 2016, signed by the President on
April 26, 2016 that mandated the DOH to formulate a long-term plan towards TB
elimination; (2) the DOH-issued Philippine Health Agenda with the vision of All for
Health towards Health for All that included TB as a disease for action under its seven
ACHIEVE strategies; and (c) the End TB Strategy endorsed by the World Health
Assembly in 2014 where the Philippines was one of the signatories. PhilSTEP1
envisions a TB-free Philippines by reducing TB incidence and mortality by 90% and
95% respectively in 2035, reducing catastrophic cost to zero and ensuring a
responsive health service delivery system.

The DOH, in collaboration with NTP partner agencies and the World Health
Organization (WHO), spearheaded the planning of the 4th NTPS. The Philippine
Council for Health Research and Development (PCHRD), which managed the DOH
NTP research funds, oversaw the implementation of the NTPS by a consortium of
research partners led by the Foundation for the Advancement of Clinical
Epidemiology, Inc. (FACE, Inc.) in cooperation with the University of the Philippines
Manila. Most of the resources were shouldered by the DOH, with some technical

13
and/or financial support from the Global Fund to Fight AIDS, TB and Malaria through
the Philippine Business for Social Progress, WHO, and the United States Agency for
International Development (USAID). The pilot study and the preparations for the NTPS
started in the last quarter of 2015 up to the first quarter of 2016, while the field work
was carried out from March to December 2016.

14
2. STUDY OBJECTIVES

The overall goal of the 4th NTPS was to gain a much better understanding of the
burden and trend of disease caused by TB and to identify ways in which TB control
and care can be improved, in order to ensure that TB is no longer a public health
threat.

2.1. Primary objectives

1) To determine the prevalence of pulmonary TB (PTB) among the population in

the Philippines aged 15 years or older for the period 2016, specifically:

a) Acid-fast bacilli (AFB) smear-positive PTB

b) Xpert-positive PTB

c) Bacteriologically confirmed PTB

2) To assess the trend in TB prevalence with smear-positive PTB and

bacteriologically-confirmed TB, compared with the results of the 2007
previous survey; and

3) To contribute to baseline data for related SDGs and End TB Strategy targets.

2.2. Secondary objectives

To determine the following:

1) Role of TB presumptive symptoms in case detection;

2) Radiological abnormalities suggestive of PTB;

3) The relationship between TB prevalence and socioeconomic factors;

4) The relationship between TB and risk factors of smoking and diabetes

mellitus;

5) Rifampicin resistance by Xpert MTB/RIF;

6) Health care-seeking behavior of TB prevalent cases and individuals reporting

TB presumptive symptoms.

15
7) Use of the private sector for TB care, as reflected by the proportion of TB
patients under treatment in the private sector.

8) To the extent possible, an estimation of possible missing cases routinely

reported to the NTP.

16
3. ORGANIZATIONAL STRUCTURE

Three layers of management were established to ensure efficient governance in the

conduct of the 2016 NTPS. The Survey Steering Committee (SC), which provided
overall leadership and oversight, was chaired by the Undersecretary of Health for the
Office for Technical Services. The Survey Technical Working Group (TWG), which
served as the technical expert panel for the NTPS, was chaired by the NTP manager.
The SC and TWG members were managers and technical experts from DOH, partners
from the public and private sectors, and international experts.

The implementing agency for the 2016 NTPS was a consortium of partners led by the
FACE, Inc., in collaboration with the Foundation for the Control of Infectious Diseases
(FCID, Inc.), and the Philippine College of Radiology. A network of TB laboratories
recommended by the Technical Working Group (TWG) and led by the National TB
Reference Laboratory (NTRL) carried out the laboratory examinations.

The project team was composed of 4 main units: (1) the Administration & Finance Unit,
(2) the Central Technical Unit, (3) the Field Survey Unit, and (4) the Quality
Management Unit (QM-Unit). The project leader, together with the deputy directors,
comprised the Executive Committee, made project level management decisions,
regularly updated the TWG on progress of work, and ensured that the project was on
track in relation to its milestones and deliverables. The Project Coordination
Committee consisted of the Executive Committee members and the heads of the
different units and teams of the project.

The organizational structure to effectively implement the 2016 NTPS is shown in Fig.
1. Details of the framework for survey operations are found in Annex A.

17
Figure 1. 2016 NTPS organizational structure

18
4. METHODS

4.1. Survey design and coverage

The NTPS was a population-based, cross-sectional survey of TB prevalence

conducted nationwide from March to December 2016. This involved a nationally
representative sample of individuals aged ≥15 years residing in selected clusters
based on stratified, multi-stage cluster sampling with population proportional to size
(PPS). The four strata were: stratum 1—the National Capital Region, Region 3 and
4A; stratum 2—the rest of Luzon; stratum 3—Visayas; and stratum 4—Mindanao. The
methodology for 2016 NTPS is described in detail in Annex B.

The sample size required for the 2016 survey was calculated using the following
assumptions: (1) the prevalence of smear-positive TB among individuals aged ≥15
years in 2016 was assumed to be 2.6/1,000, a lower prevalence compared with
3.2/1,000 in 2007; (2) a cluster size of 500 eligible survey participants aged ≥15 years;
(3) a coefficient of between-cluster variation (κ) of 0.8 (equivalent to a design effect of
1.83 in this condition); (4) a relative precision of the estimate of at least 25%; (5) a
minimum participation rate of 85%; and (6) a confidence level of 95%. Thus, a sample
size of 50,834 eligible participants was required.

The sample size to determine the prevalence of bacteriologically confirmed TB (BCTB)

was estimated at 48,969 eligible individuals. This sample size was calculated based
on the following assumptions: (1) the prevalence of BCTB among those aged ≥15
years in 2016 was assumed to be 5.8/1000, a lower prevalence compared with
7.8/1000 in 2007; (2) a cluster size of 500 eligible survey participants aged 15 years
or older (3) a design effect of 2.0; (4) a relative precision of the estimate of at least
18%; 5) a minimum participation rate of 85%; and (6) a confidence level used of 95%.

Based on the above requirements and assumptions, a sample size of 51,000 (that is,
500 eligible individuals from 102 clusters) was adopted. Six clusters were added to
round off the number allocated to each stratum and to secure the sample size in case
survey operations in the Autonomous Region in Muslim Mindanao (ARMM) had to be
cancelled in high security areas and/or inaccessible areas. Thus, the final number of
clusters targeted was 108, equivalent to a sample size of around 54,000.

19
The allocation of clusters across strata was proportionate to the population sizes of
the strata according to the 2010 census of population by the National Statistics Office
(NSO), now the Philippine Statistics Authority (PSA). Consequently, the 108 clusters
were allocated as follows: 41 clusters for stratum 1, 20 for stratum 2, 21 for stratum 3,
and 26 for stratum 4.

4.2. Study population

A total of 106 clusters were surveyed out of the 108 that were randomly sampled. The
survey covered 57 provinces from the 18 regions of the Philippines. Nine cities from
NCR were also included. Figure 2 shows a map of the Philippines with the location of
survey clusters marked. Annex B shows the distribution of clusters per stratum and
the barangays included in each stratum and provides a detailed description of the
circumstances behind the exclusion of two clusters and replacement of four clusters.

Figure 2. Figure of the Philippines with clusters marked

4.3. Field survey proper

Four survey teams, consisting of 11 members per team, were deployed to conduct the
survey simultaneously. Two teams were deployed to the clusters in Luzon, including
those in the NCR. One team was deployed to the Visayas and another to Mindanao.

20
Each team spent 7 days in the cluster. In instances when problems like inclement
weather, travel-related delays, or low survey participation rate were encountered, the
team extended its stay in the cluster up to a maximum of 10 days. The typical survey
week schedule was as follows:

Day Activity
0 Arrival of the team
Courtesy call with local chief executives and key local health
unit staff
Household census
1 Household census
Set-up of the survey operations site
2, 3, 4, 5 Survey field operations
6 Mop-up operations
Dismantling of field operations site
Debriefing meeting

Fig. 3 shows the overall process flow at the field survey site. All survey participants
were asked to register upon arrival at the survey site. Eligibility for participation in the
survey was based on age (≥15 years old) and residency in the cluster (residing in the
cluster for the last two weeks prior to the survey or living in the household 50% of the
time in the past month). The eligibility of the participants was confirmed by checking
the list of survey-eligible individuals in the household registry that was prepared by the
team after conducting the household survey.

Figure 3. Physical set-up and flow at the survey site

21
Each field team had four interviewers who administered the survey questionnaire
consisting of 72 questions (Annex F, Form 2.5). The interview took 10 minutes on the
average, with a range of 5–15 minutes. The questionnaire was translated into the
major Philippine languages including Tagalog, Ilocano, and Bisaya. The questions
were grouped by topic, namely: (1) TB symptoms screening (cough, sputum
production, hemoptysis, fever, weight loss, night sweats) and symptom screening
results; (2) past history of TB diagnosis and treatment (year of last diagnosis, type of
TB, place of treatment, duration of treatment); (3) current status of TB diagnosis and
treatment (type of TB and place of treatment); (4) health care seeking behavior for
those with symptoms; (5) diabetes mellitus; and (6) smoking habits.

Eligibility for sputum collection based on the presence of the screening symptoms for
PTB was determined during the interview. Screening questions for presumptive TB
and sputum eligibility were: cough with a duration of two weeks or more, blood in the
sputum, and/or hemoptysis. All participants who had any of these screening symptoms
were considered eligible for sputum collection. After the interview, field interviewers
directed all participants to the chest X-ray station.

4.4. Chest X-ray

4.4.1. Chest X-ray procedure

Each field team was equipped with a mobile digital chest X-ray machine (details are
found in Annex B). For participants who consented to have a chest X-ray taken, the
radiology technologist ensured that all necessary preparations for the procedure were
observed according to the chest X-ray SOPs.1 After taking the chest X-ray, the
radiology technologist saved the digital X-ray file on the X-ray machine’s computer
and then directed to the station of the field team leader.

For all participants who declined or were not eligible for X-ray imaging, the field team
leader probed the reasons for refusal and, where applicable, tried once more to

1 A compendium of all SOPs in the 2016 NTPS are available on request.

22
persuade the participant to have the procedure done. Those who refused chest X-ray
imaging were directed to the sputum collection station, where they were asked to
submit sputum specimens, regardless of the presence of signs and symptoms
suggestive of TB.

4.4.2. Chest X-ray reading by the field team leader

Upon arrival at the X-ray reading station, the field team leader retrieved the digital X-
ray image of each participant through a local area network at the field survey site and
checked the image for abnormalities suspicious for TB. The field team leader classified
the X-ray image as normal, abnormal consistent with TB, or abnormal but not
consistent with TB and assessed whether the participant was eligible for sputum
collection based on screening questions and/or radiographic findings. Participants
who were eligible for sputum collection based on symptoms and/or radiographic
findings suggestive of PTB were directed to the sputum collection station. Participants
with radiographic findings that were indicative of conditions other than TB and who
needed further assessment were referred to the local health unit for appropriate
management.

4.4.3. Chest X-ray reading by the off-site radiologist

At the end of each day, all digital X-ray images were uploaded to the MinXray cloud
online storage service. The off-site radiologists accessed the digital X-ray images from
the central server. Off-site radiologists recorded readings on the designated form
(Annex F, Form 3.1). The following classification for chest X-rays, as adapted from the
WHO Handbook [WHO, 2011] were used by the off-site radiologists:

1. Abnormality detected—not TB. Chest X-ray images where the radiologist

detects some abnormality but considers it not clinically significant in relation
to PTB.

2. Pulmonary abnormality detected—not tuberculosis. Chest X-ray images

where the radiologist detects a significant abnormality and considers this as
non-tuberculosis.

3. Pulmonary abnormality detected—suspicious for tuberculosis. Chest X-ray

images that show abnormalities usually associated with PTB.

23
All electronic forms were uploaded for submission. In cases when uploading was not
possible (e.g., poor internet connectivity), the forms were submitted through password-
protected data storage devices (e.g., flash drives, optical discs, external hard drives)
or using paper forms in sealed envelopes. Readings from the off-site radiologist were
expected to be given to the field teams within 6 hours of notification that chest X-rays
had been uploaded to the cloud for reading.

In clusters where a reliable internet connection for transmitting X-ray images was not
available, a local radiologist was recruited to act as the off-site radiologist. The local
radiologist was expected to give the results within 18 hours of notification. Overall,
there were local radiologists recruited to read chest X-ray images in six clusters where
the internet connection was poor to nil, while eight off-site radiologists based in Metro
Manila interpreted the bulk of the chest X-ray images.

Participants whose chest X-rays were read by the off-site or local radiologist as
suggestive of TB but were not read as such by the field team leader were traced with
the help of the local community volunteers or health center staff and recalled to the
survey site for sputum collection. Participants with chest X-rays identified as
suggestive of TB by the field team leader but not as such by the off-site or local
radiologist were still considered eligible for sputum collection.

4.4.4. Chest X-ray reading by central radiologist

Six central radiologists downloaded the chest X-ray images from the cloud online
storage and read them, noting their findings on the designated form.

Central radiologists read a subset of the chest X-rays taken, namely: (1) all abnormal
chest X-ray images (both suggestive of TB and not suggestive of TB); (2)
disagreements between the readings of the field team leader and the off-site
radiologist; (3) chest X-ray images of individuals with any positive sputum examination
result; and (4) random sample of 5% of the chest X-ray images read as normal by both
the field team leader and the off-site radiologist. For the final classification of the
participants by the Diagnostic and Medical Panel, readings by the central radiologists,
when done, were considered final.

24
4.5. House-to-house interviews

House-to-house interviews were conducted starting on Day 4 until the day before mop-
up operations. This was done to ensure participation from eligible individuals with
physical limitations that prevented them from going to the survey site. Eligible
individuals who had not yet participated in the survey were also reminded to go to the
survey site. Eligible individuals who refused to go to the survey site but consented to
participate were interviewed at home.

Interviews were conducted at the participant’s house, or at their place of work, or at

any place convenient for them. The interviews followed the same procedures as on-
site interviews. After the interview, the participant was requested to go to the survey
site for chest X-ray if they consented to the procedure. Participants who declined chest
X-ray were asked to submit sputum. Participants who refused to participate were
asked for their reasons for not wanting to participate.

4.6. Sputum collection in the field

Sputum-eligible participants were asked to provide 2─3 sputum specimens, with each
specimen labeled as follows:

S1—the first collection of a spot specimen at the field survey site

S2—an early morning specimen (usually collected the next day)

S3—an additional spot specimen shortly after the early morning specimen was
submitted for examination. This was collected whenever the previous sputum
specimens given had a volume of less than 3 mL

The sputum specimens from the field site were transported to the designated
laboratory in coolers (2─8ºC) at least twice a week.

4.7. Laboratory procedures

4.7.1. Fluorescence microscopy

Direct sputum smear microscopy was done using light-emitting diode fluorescence
microscope (LED-FM). Reporting was based on WHO/IUATLD recommendations
[Global Laboratory Initiative 2014]. The national reporting scale for AFB using the
fluorescent microscope was followed as shown in Table 2.

25
 Table 2. National reporting scale for AFB microscopya

Fluorescence Microscopy
Reporting Scale
200x magnification 400 x magnification
0 No AFB/1 length No AFB/1 length
Confirmation requiredb 1─4 AFB/1 length 1─2 AFB/1 length
Scanty 5─49 AFB/1 length 3─24 AFB/1 length
1+ 3─24 AFB in 1 field 1─6 AFB in field
2+ 25─250 AFB in 1 field on 7─60 AFB in 1 field on
average average
3+ >250 AFB in 1 field on >60 AFB in 1 field on
average average
a Source: adapted from DOH (2014a) National Tuberculosis Control Program: Manual of Procedures, 5th ed.
b A second microscopist reads the smear for confirmation

4.7.2. Mycobacterial culture

Solid culture (Ogawa method) was utilized during the survey. All Ogawa media were
outsourced and underwent quality control from the supplier as verified by the Quality
Management-Laboratory team.

Two tubes were used for each specimen and labeled with the corresponding
laboratory barcode. Observation for growth was done every week until the end of 8
weeks. Tubes observed to have colony growth were sampled, smeared, and stained
by Ziehl Neelsen stain. Those read as AFB positive were subjected to the MPT 64
Rapid Test for confirmation of M. tuberculosis. Negative results were recorded at the
end of eight weeks incubation. Contaminated tubes were also recorded into the culture
worksheet (Annex F, Form 4.3).

Table 3 shows the standard reporting scheme followed in reporting growth from solid
culture.

Table 3. Standard reporting scheme for growth in solid culturea

Laboratory
Growth Ziehl Neelsen MPT64 ID Final result
report
None No growth Not applicable Not applicable Negative
1–9 colonies Record actual Positive Positive MTB
number Positive Negative NTMb
Negative Not applicable Negative
10─100 colonies 1+ Positive Positive MTB
Positive Negative NTM
Negative Not applicable Negative
>100─200 2+ Positive Positive MTB
colonies Positive Negative NTM
Negative Not applicable Negative

26
 >200 or too 3+ Positive Positive MTB
numerous to Positive Negative NTM
count Negative Not applicable Negative
Contaminated 1/3contaminated Not applicable Not applicable Contaminated
½ contaminated
¾ contaminated
Liquefied or fully
contaminated
a Source: adapted from Global Laboratory Initiative (2014)
b NTB: non-tuberculous mycobacterium

4.7.3. Xpert MTB/RIF test

All S1 specimens were processed for Xpert MTB/RIF determination, unless S1 had an
inadequate volume or was bloody, in which case, the S2 or S3 specimen was used
and duly recorded as such. If S1, S2 and/or S3 specimens were all less than 1 ml
each, the available specimens were pooled so that the final specimen to be used for
Xpert could meet the minimum volume of 1 ml.

Results were interpreted as follows:

 MTB DETECTED: MTB result displayed High, Medium Low or Very Low
 Rifampicin Resistance DETECTED: mutation in the rpoB gene was detected
 Rifampicin resistance NOT DETECTED: no mutation in the rpoB was detected
 Rifampicin resistance INDETERMINATE: MTB concentration was very low and
resistance could not be detected
 MTB NOT DETECTED: MTB target DNA was not detected
 RIF NOT DETECTED: Rifampicin target DNA was not detected
 INVALID: presence or absence of MTB cannot be determined, and so a repeat
test with extra specimen (if available) is recommended

4.8. The Diagnostic and Medical Panel

The Diagnostic and Medical Panel was composed of two pulmonologists, two
infectious disease specialists, a senior radiologist, the laboratory coordinator, one data
manager from the data management unit, and the deputy director of the Central
Technical Unit. The main function of the Diagnostic and Medical Panel was to decide
on the survey classification of positive cases and to give clinical recommendations and
feedback to the municipal health officers (MHOs) and/or NTP coordinators of the
respective clusters. Each case for discussion was presented with the following

27
information: barcode, ID, age and sex, household number, symptoms, history of
treatment, history of diabetes mellitus and smoking, Xpert, direct sputum smear
microscopy (DSSM) and culture results including quantification, chest X-ray images
and the interpretation of the radiograph by the central senior radiologist. Table 4
describes the case definition algorithm used by the Diagnostic and Medical Panel

The following survey definitions were used:

Screening Positive was defined as follows:

 By interview: cough for two weeks at the time of the interview or more and/or
blood in sputum (hemoptysis) in the past month AND/OR
 By chest X-ray: any abnormality in the lung or mediastinum that can suggest
TB

Table 4. Case definition algorithm used by the Diagnostic and Medical Panel

Xpert DSSM Culture CXR central Survey case Categorya

result result (MTB) reading classification
Positive Positive Positive (any) Any Case S+B+
Positive Positive Negative/NTM/ Any Case S+B+
Contamination
Positive Negative Positive (any) Any Case S-B+
Positive Negative Negative Any Case S-B+
Positive NA NA Any Case S? B+
Negative Positive Positive (any) Any Case S-B+
b
Negative Negative Positive (strong) Any Case S-B+
Negative Negative Positive (weak)c Suggestive Case S-B+
Negative Negative Positive (weak) c Normal/not Non-cased S-B+
suggestive
Negative Negative Positive (weak) c NA Non-cased S-B+
Invalid/NA Positive Positive (any) Any Case S+B+
Invalid/NA Negative Positive (strong)b Any Case S-B+
c
Invalid/NA Negative Positive (weak) Suggestive Case S-B+
Invalid/NA Negative Positive (weak) c Normal/not Non-case Non-case
suggestive
Invalid/NA Negative Positive (weak) c NA Case S-B+
a S+: smear positive, S-: smear negative, B+: bacteriologically positive, B-: bacteriologically negative
b Strong culture: ≥ 10 colonies
c Weak culture: 1─9 colonies
d Equivocal cases deemed by the Diagnostic & Medical Panel as non-cases when the culture is weakly

positive and other symptoms and signs (chest X-ray, smear, and culture) are negative or not done.

28
Positive laboratory results were defined as follows:

 Positive on DSSM, or culture MTB, or Xpert MTB/RIF

Based on the symptom screening and laboratory results, bacteriologically confirmed
TB (BCTB) cases were defined as:

 Culture MTB positive AND/OR

 Xpert MTB positive AND
 Certified by the Diagnostic and Medical panel
The Diagnostic and Medical Panel reviewed the results in detail and gave special
attention to the following situations before certifying a participant as a TB case or non-
case:

1. Culture positive results are clustered (potential laboratory cross-

contamination);
2. Single scanty smear or Xpert positive without any other bacteriological
evidence;
3. Discrepancy between clinical information and bacteriologically positive result/s
(possible recording error or mix-up); or
4. Culture negative, Xpert positive cases with a history of TB treatment (TB
disease vs dead bacilli)
5. Weak culture positive without other bacteriological evidence and X-ray not done
or not suggestive of TB
The Diagnostic and Medical Panel ensured that false-positive diagnoses of TB due to
data management errors and/or cross-contamination in the laboratory were detected
and that these participants were classified as non-cases.

Upon completion of the case classifications, two members of the WHO technical
assistance team reviewed the case book, the associated laboratory results, and chest
X-rays to validate the Diagnostic and Medical Panel’s findings.

Case management. After completion of the case discussions per cluster, the co-
chairs of the Diagnostic and Medical Panel and the project leader e-mailed the
password-protected results (or by courier for those with poor or nil internet
connectivity) to the city/municipal health officer and the NTP coordinator of the cluster
for appropriate management and/or evaluation of the bacteriologically confirmed PTB
cases. The information provided on the BCTB cases included the name, age, address,

29
symptoms if any, chest X-ray findings, all laboratory results, and recommendations for
management by the Diagnostic and Medical Panel. A mini-inventory of the BCTB
cases was also conducted after the survey to determine actions carried out by health
officers in the clusters with BCTB cases. The methods and results of the mini-inventory
are found in Annex D.

4.9. Quality management procedures

The QM unit undertook quality assurance and quality control processes and
procedures to ensure satisfactory achievement of project objectives. The QM
Coordinator (Epidemiology) and QM Coordinator (Laboratory) implemented and
supervised quality management activities (quality audits and monitoring of process
performance metrics). Quality assurance and quality control activities were performed
in coordination with the field teams and the participating laboratories. The QM unit in
collaboration with NTPS project directors and unit heads implemented QM
recommendations (preventive and corrective actions) to ensure that all processes
complied with project and organizational standards.

External technical assistance was provided to the NTPS project team through the
World Health Organization Global Task Force on TB Impact Measurement
(WHO/GTB/TME) and the WHO Country Office, commencing at the protocol
development phase in 2015, the pilot early survey phases, the midterm joint external
evaluation, validation of the NTPS results, and analyses consisting of missing data
imputations and inverse proportional weightings.

For QM performance, metrics were established and used to measure quality of the
processes and the products throughout the project life cycle. Metrics included
adherence to SOPs and benchmarks for process performance as well as product
performance/quality.2 Methods and metrics used for QM-Epidemiology and QM-
Laboratory are described in detail in Annex B.

2 The 2016 NTPS Compendium of SOPs is available on request.

30
4.10. Data management and analysis

4.10.1. Data management flow

Figure 4 shows the NTPS data management flow of data from the field survey sites to
the central office. A detailed description of the data management flow and activities is
provided in Annex B. The project team employed computer-assisted personal
interviewing (CAPI) to capture survey data using laptops, tablet PCs, and wireless
routers. Field team members used their tablets during the interviews and the
responses of the participants were encoded directly to the computer. Data, including
survey barcodes and individual identifiers, were captured electronically from the field
survey sites, reference laboratories, off-site radiologists, and central radiologists.
However, central radiologists mainly used a paper-based form to record the chest X-
ray readings and data encoding was done at the central data management unit.

Figure 4. NTPS data management flow

Data entry and data checking programs were constructed for six survey forms covering
data entry for the field, the laboratories, and the online chest X-ray forms for the off-
site radiologists and central radiologists. Epi Info versions 3.5.4 and 7.1 (Dean et al.
2011) were used to develop the data entry and data checking programs utilized by the
field survey teams and the reference laboratories. Online users such as the off-site
radiologists and some central radiologists also entered data through an online data
entry program using DrupalTM (www.drupal.org).

31
The Department of Science and Technology (DOST) hosted the online DrupalTM NTPS
website with the URL: http://ntps.healthresearch.ph (Fig. 5).3 The field data checkers,
off-site radiologists, laboratory technologists at the participating laboratories, central
radiologists, and data management unit staff were given access to the website data
entry and upload modules, while other consultants and stakeholders were given
limited access to the basic modules of the NTPS website. The central data
management unit gathered all electronic databases from the field teams, reference
laboratories, off-site radiologists, and central radiologists using the website.

Figure 5. 2016 NTPS website

The data managers and the central data checker prepared data checking and data
cleaning scripts using Epi Info 3.5.4, which were dispatched to all field survey teams.
Data processing at the central data management unit involved the following functions
for all data coming from the field survey teams and participating laboratories: data
encoding, cleaning, validation, verification, sorting, merging multiple databases,
appending data files, and data analyses.

STATA version 14.0 [StataCorp. 2015] was used for the main data management and
analysis procedures.

3 Migration to the DOH website and information system is planned at the end of the survey.

32
4.11. Statistical analysis

Statistical analysis consisted of estimation of prevalence, situation analysis of health

seeking behavior of individuals suspected of TB, and determination of risk factors for
tuberculosis. STATA 14 software [StataCorp 2015] was used to perform all statistical
analysis.

4.11.1. Survey measures

The following prevalence estimates were obtained from the survey:

 Prevalence of bacteriologically confirmed PTB among persons aged ≥15 years

 Prevalence of smear-positive PTB among persons aged ≥15 years
 Prevalence of Xpert MTB/RIF PTB among persons aged ≥15 years
 Prevalence of TB-symptomatic individuals among persons aged ≥15 years
 Prevalence of radiologically-suggestive PTB among persons aged ≥15 years
 Health-seeking behavior of symptomatic individuals and those with previous TB
treatment
 Utilization of health services among symptomatic individuals
 Association between TB prevalence and possible risk factors such as smoking
and socioeconomic status
4.12. Statistical analysis to estimate the prevalence of BCTB

With support from the World Health Organization technical assistance team, three
methods were done to estimate the prevalence of bacteriologically confirmed
tuberculosis: (1) cluster-level analysis, (2) individual-level analysis, and (3) estimation
with inverse probability weighting (IPW), and with multiple value imputation (MI) [Floyd
et al. 2013; WHO 2011]. The estimates using Method 3 were considered as the final
estimates of BCTB prevalence for the 2016 NTPS population of the Philippines.
Details of these analyses are described in Annex B and by Floyd et al. [2013].

4.12.1. Describing survey data

Frequency and percent distributions, means and standard deviations, medians,

minimum and maximum values, and percentile values were generated to describe the
survey data, where appropriate. The variables included household data, individual
interview data, chest X-ray data, and laboratory data. Summary statistics were

33
presented using tables and graphs. STATA 14 was used to generate all tables and
graphs.

4.12.2. Tests of significance

Significance tests were performed at 1% level of significance in view of the number of

significance tests done. The 95% confidence intervals of estimates were also
calculated. Chi-square test or Fisher’s exact test, and Spearman rank correlation were
performed, where appropriate. The sensitivity and specificity of laboratory tests were
also computed.

4.12.3. Multivariable analysis for determining association of possible risk

factors for TB

The association of possible risk factors for BCTB was determined using logistic
regression analysis for surveys, with inverse probability weights applied to the survey
participants and clustering of individuals being accounted for in the analysis. The
following risk factors were considered in the logistic regression analysis: older age
group, male sex, urban location, no schooling, no health insurance coverage,
unemployment, not owning a functional refrigerator, tenure of house and lot, mixed but
predominantly salvaged/makeshift materials of house, beneficiary of Pantawid
Pamilyang Pilipino Program (4Ps) or conditional cash transfer, migration, high pack-
years of smoking, having diabetes, ever had previous treatment for TB, and large
household size.

Backward elimination strategy was employed to determine risk factors that are
associated with BCTB. Odds ratios and their corresponding confidence intervals were
obtained. Variables significant at a 5% level of significance were retained in the final
model. Details of the multivariable logistic regression analysis are found in Annex B.

4.12.4. Determining inter-observer agreement between chest X-ray readings

Kappa statistics were calculated to determine the inter-observer agreement of chest

X-ray readings by the field team leaders and off-site radiologists.

The chest X-ray images that were read by the central radiologists were as follows: (1)
read as “pulmonary abnormality (suggestive of PTB)” by the field team leaders; (2)
read as pulmonary abnormality (TB or not TB) or any abnormality (not TB) by the off-
site radiologists; and (3) X-ray images of those with positive laboratory results in any

34
of the tests (Xpert, DSSM or MTB culture). In addition, 5% of the chest X-ray images
read as normal by both the field team leader and the off-site radiologist were randomly
sampled and retrieved for rereading by the central radiologists. Kappa statistics were
also computed to assess the agreement between the combined field team leader and
off-site radiologist readings, and central radiologist readings. Stata 14 was used to
calculate kappa statistics and the corresponding 95% confidence intervals.

4.13. Ethical considerations

The study protocol, SOPs, data collection forms, and consent forms were approved
by the National Ethics Committee (NEC) prior to the initiation of the study and data
collection (see Annex E for a copy of the NEC approval). The NEC was informed of
the progress of the survey, any protocol deviation, violation, and study misconduct.

An informed consent form was developed in English. There were translations in

Tagalog, Ilocano, Hiligaynon, and Bisaya. The translations were corrected, simplified
and were the bases for the creation of scripts for the audio-visual format of the
information sheet and informed consent form. (Annex E)

Potential participants were briefed by the field receptionist regarding the purpose of
the survey and the survey procedures. The audio-visual presentation of the informed
consent form was administered using a dialect of the participant's choice and
comprehension, together with the written informed consent forms in the appropriate
language. The process allowed maximal interaction to address the potential
participants' questions. The field interviewers documented comprehension by asking
simple questions related to the content of the information sheet.

The study was done in accordance with the Data Privacy Act of 2012 (Republic Act
No. 10173). The study employed the highest standards that could maintain privacy
and confidentiality of data. Bar coding was done on all participants' study records
including all case report forms, diagnostic results, chest X-rays, and chest X-ray
reports. Paper files were secured in locked filing cabinets with limited access. All
electronic files were coded and did not contain identifying information. All electronic
files and back-up copies were kept in secure servers with limited access. Survey
databases and scanned copies of individual participants’ records (approximately
422,000 pages) are to be archived for 10 years by the DOH NTP in cooperation with
the Knowledge Management and Information Technology Service of DOH.

35
5. RESULTS

5.1. Census of clusters and survey-eligible population

The total enumerated population from the 106 clusters was 89,663. Of these, 68.6%
(61,466) were eligible to participate. Among those not eligible to participate, majority
were younger than 15 years (98.9%) while the rest did not fulfill the residency criterion.
The flow diagram (Fig. 6) provides an overview of the entire survey process from the
census to the identification of the bacteriologically confirmed cases.

Of the 46,689 (76%) individuals who participated, 13,517 (28.9%) individuals were
positively screened (eligible for sputum collection) by either screening symptoms,
chest X-ray or both, and were therefore eligible for sputum collection. Of the positively-
screened participants, the majority (57.5%) had chest X-ray findings consistent with
PTB, as read by the field team leader and/or off-site radiologist. Sputum was also
collected from 5,080 (10.9%) participants who were asymptomatic but did not have a
chest X-ray or, in one participant, did not have a chest X-ray reading because of a
poor image. A total of 39.8% (18,597) of the survey participants were thus eligible for
sputum collection.

Among the 18,597 participants eligible for sputum collection, 16,242 (87.3%)
submitted at least one sputum specimen. Among the 2,355 individuals who did not
submit sputum, 2,266 (96.2%) refused to provide sputum.

Xpert MTB/RIF, DSSM, and culture were performed on the sputum specimens. Of the
16,242 individuals who submitted at least one sputum, 480 (3%) had at least one
positive laboratory result for TB, as shown in Fig. 6. All laboratory results were negative
in 14,763 (90.9%) of participants who submitted sputum, while 998 (6.1%) had other
laboratory results such as growth of non-tuberculous mycobacteria or contamination
(see Fig. 6).

Among the participants with at least one positive laboratory result, 466 (97.1%) were
classified as BCTB cases by the diagnostic and medical panel after considering all
available data from the field interviews, chest X-ray results, and laboratory results.

36
 Not eligible to participate: 28,197
(31.4%) Eligible to participate: 61,466 (68.6%)
Not eligible by age: 27,885 (98.9%)
Not eligible by residence: 247 (0.9%)
Missing eligibility data: 65 (0.2%)
32

Did not participate: 14,777 (24.0%) Participated: 46,689 (76.0%)

Interview and CXR: 41,444 (88.8%)
Interview only: 5,245 (11.2%)

Eligible for sputum examination: 18,597

(39.8%)
Positively screened: 13,517 (28.9%)
Not eligible for sputum examination: Symptom and CXR-positive (FTL/OSR): 1,358 (7.3%)
28,092 (60.2%) Symptom-positive only: 1,457 (7.8%)
CXR-positive only: 10,702 (57.5%)
Symptom-negative, no CXR taken: 5,079 (27.3%)
Symptom-negative, no CXR reading: 1 (0.0%)

Did not submit sputum: 2,355 (12.7%)

Refusal: 2,266 (96.2%) Submitted at least one sputum
Unable to expectorate: 7 specimen: 16,242 (87.3%)
Incorrect FTF marking: 79 Submitted two sputum specimens: 15,547
Invalid sample given: 1 Submitted only one specimen: 695
Unknown reason: 2

No laboratory result (1): Laboratory results available

Received 1 specimen only; tested with Xpert twice -both error;
no DSSM and AFB culture (by participant): 16,241 (99.9%)
1 smear, 1 Xpert, 1 culture: 15,991 (98.5%)
1 smear, 1 Xpert: 26 (0.2%)
1 smear, 1 culture: 41 (0.3%)
Xpert only: 183 (1.1%)
Culture only: 0
Smear only: 0
1 Xpert, 1 culture: 0

At least one positive laboratory result: 480 Other laboratory results:

All laboratory results negative: 998 (6.1%)
14,763 (90.9%) (3.0%)
Culture (+) for NTM: 502 (50.3%)
Xpert (+): 397 (82.7%)
Contaminated: 250 (25%)
Culture (+): 232 (48.3%) Xpert error/invalid, NTM (+): 1 (.1%)
DSSM (+): 183 (38.1%) Xpert error/invalid: 38 (3.8%)
Culture not done: 205 (20.5%)
Panel review Xpert not done: 2 (0.2%)

TB Case: 466 Not TB: 14

DSSM (-): 289 DSSM (+): 173

Xpert (+) only: 189 Xpert (+) only: 45 DSSM (not done): 4
Culture (+) only: 50 Culture (+) only: 19 Xpert (+) only: 4
Xpert and culture (+): 50 Xpert and culture (+): 109

Figure 6. Flow diagram of 2016 NTPS, Philippines based on 106 clusters

37
5.1.1. Household profile in the clusters surveyed

The prevalence survey covered a total of 19,707 households from 106 clusters, with
a total population of 89,663. The average number of individuals in the clusters was
581 (range: 496─767). The highest number of participating households was from
stratum 1, followed by stratum 4, stratum 2, and stratum 3. The median size of the
households in all strata was 4 (range: 1–17) members in a household (Table 5).

Table 5. Distribution of clusters and households, 2016 NTPS, Philippines

(N=106 clusters)

No. of No. of Median size of

No. of
Stratum households household household
clusters (%)
(%) members (Range)
1 40 7,239 4.0
33,628
(37.7) (36.7) (1–17)
2 20 3,937 4.0
17,544
(18.9) (20.0) (1–15)
3 21 3,819 4.0
17,049
(19.8) (19.4) (1–16)
4 25 4,712 4.0
21,442
(23.6) (23.9) (1–17)
Overall 106 19,707 89,663 4.0

The overall household participation for the survey, based on the participation of at
least one member of the household, was 95.5%, with strata 2, 3, and 4 at
approximately 98% each, and stratum 1 at 91.5% (P<0.0001). Based on geographical
distribution, majority of the households were from rural areas (53%). Household
participation from rural clusters was also higher (97.6%) compared to urban areas
(93.2%) (P<0.0001) (Table 6).

Several household characteristics were included in the survey as markers for socio-
economic status: housing tenure, house construction materials, and presence of a
refrigerator or freezer. Household participation according to these indicators of
socioeconomic status was then analyzed. In general, the participation rate was higher
among households with lower socioeconomic status as indicated by the following:
salvaged or light construction materials for exterior walls and absence of a cool
storage appliance. Housing tenure did not appear to differentiate between participating
and non-participating households (Table 7).

38
 Table 6. Household participation by stratum and geographical location,
2016 NTPS, Philippines (N=19,707 households)

Total
Participating households
Characteristics households
No. %a %b No. %a
Stratum
1 6,621 35.2 91.5 7,239 36.7
2 3,849 20.4 97.8 3,937 20.0
3 3,751 19.9 98.2 3,819 19.4
4 4,609 24.5 97.8 4,712 23.9
Geographical locationc
Urban 8,642 45.9 93.2 9,269 47.0
Rural 10,188 54.1 97.6 10,438 53.0
Total 18,830 100.0 100.0 19,707 100.0
a Column percentage
b Row percentage
c Based on urban/rural classification by the Philippine Statistics Authority (2010). Available at:
https://psa.gov.ph/tags/urban-rural-classification

Enrolment of the participating households in the national social welfare system

“Pantawid Pamilyang Pilipino Program” (4Ps) was also asked during the household
interviews. The 4Ps program aims to provide social assistance and social
development through conditional cash transfer and generally enrolls the “poorest of
the poor.” [Reyes & Tabuga 2012]. Of the total number of households in the 106
clusters, 20.7% were enrolled in the 4Ps program. Of those enrolled, stratum 4 had
the highest number of 4Ps recipients (37.4%), followed by stratum 1 (25%), stratum 2
(23.2%), and lastly stratum 3 (14.4%). Majority of the 4Ps recipients resided in rural
areas (72.9%), and had a household size of 5–8 (58.3%). The participation rate among
the 4,072 households that were 4Ps recipients was 98.4%.

5.1.2. Census and survey population profile

There were 89,663 individual household members enumerated in the 106 clusters.
Figure 7 compares the age and sex distribution of the population in the clusters against
the 2010 Philippine census. The percentages of the 2010 Philippine population are
similar to the age group distribution in the survey-eligible population except for the
older age groups. Individuals from the age group 55─64 years comprised 7.2% of the
survey population compared to 5.7% of the Philippine population. Individuals in the
age group ≥65 years comprised 5.9% of the survey population compared to 4.3% of
the Philippine population. On the other hand, the sex distributions in the younger age
groups (0─54 years) were comparable. The older age groups showed more females

39
in the NTPS survey population compared to the 2010 Philippines census (7.7% vs.
5.9% for age group 55─64 years, and 7.2% vs. 5.1% for age group ≥65 years).

Out of the 89,663 individual household members in the clusters, 61,466 individuals
(69%) were eligible to participate based on the age eligibility criteria of ≥15 years and
residence of at least two weeks in the cluster or slept in the household >50% of the
time in the past month (Table 8).

Source for 2010 Philippine census: Philippine Statistics Authority [2012]

Figure 7. Age and sex pyramid of the 2016 NTPS census and the 2010
Philippine census

Figure 8 shows the census population against the eligible population. This showed
that the survey census population distribution had a similarity to the age distribution to
the eligible population of the survey.

40
 Table 8. Survey population by eligibility criteria, 2016 NTPS, Philippines
(N=89,663)

Total
Age group Eligible Ineligible
enumerated
(years)
No. (%a) No. (%a) No. (%a)
0–4 0 9,144 (32.4) 9,144 (10.2)
5–9 0 9,700 (34.4) 9,700 (10.8)
10–14 0 9,012 (32.0) 9,012 (10.1)
15–24 17,048 (27.7) 115 (0.4) 17,163 (19.1)
25–34 13,039 (21.2) 84 (0.3) 13,123 (14.6)
35–44 10,800 (17.6) 44 (0.2) 10,844 (12.1)
45–54 8,882 (14.4) 32 (0.1) 8,914 (9.9)
55–64 6,447 (10.5) 21 (0.07) 6,468 (7.2)
≥65 5,243 (8.5) 11 (0.04) 5,254 (5.9)
No data on exact
7 (0.01) 34 (0.1) 41 (0.05)
ageb
Total 61,466 28,197 89,663
% 68.6 31.4

Figure 8. Age and sex pyramid for the survey census and the survey-eligible
population, 2016 NTPS, Philippines

41
 Table 7. Survey household population by household characteristics and household
participation, 2016 NTPS, Philippines (N=19,707 households)

Participating Total
households households Participation
Characteristics
Rate
No. %a No. %a
Tenure status of housing unit
Owns house and lot 9,909 52.6 10,382 52.7 95.4
Owns house, rents lot 388 2.1 399 2.0 97.2
Owns house, rent-free lot with consent of
owner 3,705 19.7 3,775 19.2 98.1
Owns house, rent-free lot without consent
of owner 756 4.0 774 3.9 97.7
Rent-free house and lot with consent of
owner 2,108 11.2 2,188 11.1 96.3
Rents house/room including lot 1,801 9.6 1,943 9.9 92.7
Rent-free house and lot without consent of
owner 59 0.3 59 0.3 100.0
Loan (bank, HDMFb) for house and lot 17 0.1 19 0.1 89.5
No house, no lot 1 0.0 1 0.0 100.0
No data 75 0.4 152 0.8 49.3
Don’t know 11 0.1 15 0.1 73.3
Construction materials of exterior walls
Strong materials 10,358 55.0 10,941 55.5 94.7
Mixed but predominantly strong materials 2,604 13.8 2,664 13.5 97.7
Light materials 4,500 23.9 4,610 23.4 97.6
Mixed but predominantly light materials 1,120 5.9 1,155 5.9 97.0
Salvaged/ makeshift materials 110 0.6 112 0.6 98.2
Mixed but predominantly salvaged
materials 48 0.3 49 0.2 98.0
Others 2 0.0 2 0.0 100.0
No data 77 0.4 159 0.8 48.4
Don’t know 11 0.1 15 0.1 73.3
Refrigerator/ freezer in the house
Yes 7,084 37.6 7,533 38.2 94.0
No 11,666 62.0 12,011 60.9 97.1
No data 69 0.4 148 0.8 46.6
Don’t know 11 0.1 15 0.1 73.3
Total 18,830 100.0 19,707 100.0 100.0
a Column percentage
b HDMF: Home Development Mutual Fund (or more popularly known as the PAG-IBIG Fund)

42
The overall participation rate, based on survey-eligible individuals who consented to
be interviewed, was 76%, as against a targeted participation rate of 85%. Nearly a
tenth (9.1%) of the participants were interviewed in their homes during the mop-up
operations (see Section 4 and Annex B on Methods).

Table 9 shows the demographic characteristics of the eligible population and the
corresponding participation and non-participation rates. Since there were more
clusters sampled for stratum 1, the percentage of survey participants out of the total
number of participants was highest in this stratum (34.4%). However, stratum 4 had
the highest participation rate (82.7%) out of its total eligible population, followed by
stratum 3 (82.0%), stratum 2 (79.4%), and lastly stratum 1 (67.3%) (P<0.0001).

In terms of age groups, individuals aged ≥65 years had the highest participation rate
(90.1%), while those aged ≤ 25 years had the lowest participation rate at 70%
(P<0.0001). However, in terms of absolute numbers, individuals in the age groups 15–
24 years comprised the largest group at 11,938 (25.6%). There were more female
participants (55.3%) than males (44.7%). The participation rate for females (82.2%)
was also higher than males (69.5%) (P<0.0001). This was true for all age groups (Fig.
8 & Fig. 9). The ratio between rural to urban residents among the survey-eligible
population was almost 1:1, but the participation rate from the rural clusters was higher
(80.2%) than the urban clusters (71.5%) (P<0.0001).

In terms of the profile of participants vs non-participants, there was a higher non-

participation rate among the eligible individuals whose highest educational attainment
was at the college or postgraduate level. With respect to occupation, housewives
(93.6%) had the highest participation rate, followed by those without formal
employment (83.8%), and agriculture/forestry/fishery (83.8%). For occupational
groups with at least 1,000 eligible individuals, the highest non-participation rates were
among professionals (48.4%), laborers (33.2%), and those engaged in sales/services
(29.5%).

43
 Table 7. Distribution of eligible population by demographic characteristics and participation in the
survey, 2016 NTPS, Philippines (N=61,446)

Total
Participants Non-participants
Characteristics eligible
No. No. %a %b No. %a
Stratum
1 23,853 16,048 34.4 67.3 7,805 32.7
2 11,769 9,348 20.0 79.4 2,421 20.6
3 11,833 9,703 20.8 82.0 2,130 18.0
4 14,011 11,590 24.8 82.7 2,421 17.3
Age group (years)
15–24 17,048 11,938 25.6 70.0 5,110 34.6
25–34 13,039 9,112 19.5 69.9 3,927 26.6
35–44 10,800 8,241 17.7 76.3 2,559 17.3
45–54 8,882 7,162 15.3 80.6 1,720 11.6
55–64 6,447 5,513 11.8 85.5 934 6.3
≥65 5,243 4,723 10.1 90.1 520 3.5
No data on exact age 7 0 0.0 0.0 7 0.0
Sex
Male 30,081 20,893 44.7 69.5 9,188 62.2
Female 31,385 25,796 55.3 82.2 5,589 37.8
Urban/rural classification
Urban 30,110 21,526 46.1 71.5 8,584 58.1
Rural 31,356 25,163 53.9 80.2 6,193 41.9
Highest educational attainment
No schooling 985 855 1.8 86.8 130 0.9
Pre-elementary, elementary 17,915 15,178 32.5 84.7 2,737 18.5
High school 23,470 18,304 39.2 78.0 5,166 35.0
Vocational 3,344 2,451 5.2 73.3 893 6.0
College, post-graduate 15,309 9,901 21.2 64.7 5,408 36.6
No data 359 0 0.0 0.0 359 2.4
Don't know 84 0 0.0 0.0 84 0.6
Occupation
Without formal employment 10,526 8,819 18.9 83.8 1,707 11.6
Sales/Service 12,227 8,623 18.5 70.5 3,604 24.4
Managers 4,906 4,004 8.6 81.6 902 6.1
Agriculture/forestry/fishery 4,574 3,832 8.2 83.8 742 5.0
Laborer 4,401 2,940 6.3 66.8 1,461 9.9
Professionals and associate
professionals 2,636 1,359 2.9 51.6 1,277 8.6
Clerks 792 364 0.8 46.0 428 2.9
Trades 881 357 0.8 40.5 524 3.5
Plant/machine operator or assembler 508 174 0.4 34.2 334 2.3
Others 676 135 0.3 20.0 541 3.7
Housewife 11,344 10,615 22.7 93.6 729 4.9
Student 7,191 5,467 11.7 76.0 1,724 11.7
No data 795 0 0.0 0.0 795 5.4
Don't know 9 0 0.0 0.0 9 0.1
Totalc 61,466 46,689 100.0 76.0 14,777 24.0
a
Column percentage
b
Row percentage
c
Note: 7 enumerated HH members with no exact age are confirmed eligible to participate

44
 Figure 9. Age and sex pyramid for survey-eligible individuals vs. actual
participants, 2016 NTPS, Philippines
100
90
80
70
60

15-24 25-34 35-44 45-54 55-64 > 65

Age group

Male Female
Note: The green line indicates the minimum participation rate targetted at 85%

Figure 10. Participation rate by sex and age group, 2016 NTPS, Philippines

45
In terms of characteristics by stratum, the percentage of survey participants out of the
total number of participants was highest in stratum 1 (34.4%). This was expected as
there were more clusters sampled from stratum 1. The age distribution of the
participants was similar across all strata, but the lowest proportion of participants aged
≥65 years came from stratum 4 (8.1%) (P<0.0001). There were more female
participants than males across all strata and age groups (P<0.0001), with the highest
proportion of females found in stratum 1 (58.3%) and in the age group 15–24 (23.9%).
On the other hand, the proportion of males was highest in stratum 4 (47.3%).

The highest educational attainment across the four strata was high school; however,
there was a higher proportion in high school among participants in stratum 1 (44.3%)
compared to the other strata (P<0.0001). Further analysis by urban/rural classification
showed that in the urban clusters, there was a higher proportion of participants with
high school as their highest educational attainment (43.2%) compared to the rural
clusters (35.8%)4 (P<0.0001). In terms of civil status, the ratio of single to married
participants in strata 2 and 4 was 1:2, while for strata 1 and 3, the ratio was 2:3. The
proportions of participants who were employed or were students were similar across
strata. Majority of the male participants were employed (65.4%), while majority of the
female participants were unemployed (57.6%)5. In terms of health insurance coverage
(including coverage by the Philippine Health Insurance Corporation, or PhilHealth for
short), the range of coverage was from 60.6–67.4% and was highest in stratum 2.
Among those insured, only 59.2% said they had PhilHealth coverage. More females
(60%) than males (58%) had PhilHealth coverage (P<0.0001).

5.1.3. Symptom screening

Out of the 46,689 survey participants, 2,815 individuals (6%) were eligible for sputum
collection based on the presence of screening symptoms alone. The proportion of
males (7.9%) who reported screening symptoms was significantly higher compared to
females (4.5%) (P<0.001). Cough of ≥2 weeks duration was the most frequently
reported symptom among those reporting screening symptoms (79.7%). The

4 Breakdown not shown, but data available on request.

5 Breakdown not shown, but data available on request.

46
proportion of participants with symptoms increased with age; the highest proportion of
participants reporting the presence of cough of ≥2 weeks duration was seen among
those aged ≥65 years (10.7%) (P<0.0001).

Tables 10─12 describe the socio-demographic characteristics of the survey

participants and those with screening symptoms. The proportion of participants
reporting the presence of screening symptoms was similar in terms of urban/rural
classification and employment status. On the other hand, only 3% of participants who
were students had any of the screening symptoms. The highest proportions of
participants who had screening symptoms belonged to stratum 4 (8.4%) (Table 11),
had no schooling (19.5%) (Table 12), and were working in the
agriculture/fishery/forestry industry (11.2%) (Table 13).

Participants were also asked about non-specific symptoms: fever, cough <2 weeks
duration, night sweats and weight loss. Majority of participants with the screening
symptoms of PTB (cough of ≥2 weeks duration or hemoptysis) did not have any of the
non-specific symptoms (52.9%). Among those with screening symptoms and one or
more of the less specific symptoms, 16.5% had at least two of the less specific
symptoms.

47
 Table 8. Socio-demographic characteristics of survey participants by stratum, 2016 NTPS, Philippines (N=46,689)

Stratum 1 Stratum 2 Stratum 3 Stratum 4 Total

Characteristics
No. %a No. %a No. %a No. %a No. %a
Age group (years)
15–24 4,053 25.3 2,366 25.3 2,416 24.9 3,103 26.8 11,938 25.6
25–34 2,990 18.6 1,823 19.5 1,858 19.1 2,441 21.1 9,112 19.5
35–44 2,782 17.3 1,673 17.9 1,620 16.7 2,166 18.7 8,241 17.7
45–44 2,548 15.9 1,404 15.0 1,503 15.5 1,707 14.7 7,162 15.3
55–64 2,011 12.5 1,071 11.5 1,193 12.3 1,238 10.7 5,513 11.8
≥65 1,664 10.4 1,011 10.8 1,113 11.5 935 8.1 4,723 10.1
Sex
Male 6,692 41.7 4,240 45.4 4,481 46.2 5,480 47.3 20,893 44.7
Female 9,356 58.3 5,108 54.6 5,222 53.8 6,110 52.7 25,796 55.3
Highest educational attainment
No schooling 113 0.7 100 1.1 103 1.1 539 4.7 855 1.8
Pre-elementary/elementary 4,308 26.9 3,373 36.1 3,288 33.9 4,209 36.3 15,178 32.6
High School 7,104 44.3 3,500 37.4 3,529 36.4 4,171 36.0 18,304 39.2
Vocational 1,023 6.4 456 4.9 439 4.5 533 4.6 2,451 5.2
College/postgraduate 3,500 21.8 1,919 20.5 2,344 24.2 2,138 18.5 9,901 21.2
Civil status
Single 4,587 28.6 2,414 25.8 2,986 30.8 3,064 26.4 13,051 28.0
Married 7,033 43.8 4,721 50.5 4,446 45.8 6,065 52.3 22,265 47.7
Currently living-in 2,744 17.1 1,398 15.0 1,359 14.0 1,600 13.8 7,101 15.2
Widowed/divorced/separated 1,684 10.5 815 8.7 912 9.4 861 7.5 4,272 9.2
Work status
Employed 7,506 46.8 4,334 46.4 4,444 45.8 5,582 48.2 21,866 46.8
Unemployed 6,709 41.8 3,943 42.2 4,054 41.8 4,650 40.1 19,356 41.5
Student 1,833 11.4 1,071 11.5 1,205 12.4 1,358 11.7 5,467 11.7
With health insurance
Yes 10,011 62.4 6,302 67.4 5,884 60.6 7,778 67.1 29,975 64.2
No 5,680 35.4 2,999 32.1 3,762 38.8 3,753 32.4 16,194 34.7
No data/don’t know 357 2.2 47 0.5 57 0.5 59 0.5 520 1.1
Total 16,048 34.4b 9,348 20.0b 9,703 20.8b 11,590 24.8b 46,689 100.0
a
Column percentage
b
Denominator is total no. of survey participants (46,689)

48
 Table 9. Socio-demographic characteristics of survey participants who had screening symptoms, 2016 NTPS, Philippines
(N=46,689)

With screening symptoms

Total survey
Cough ≥2 weeks Cough ≥2 weeks & No symptomsa
Characteristics participants Hemoptysis only
only hemoptysis
b b
No. No. % No. % No. %b No. %b
Stratum
1 16,048 616 3.8 84 0.5 54 0.3 15,294 95.3
2 9,348 296 3.2 57 0.6 30 0.3 8,965 95.9
3 9,703 610 6.3 52 0.5 41 0.4 9,000 92.8
4 11,590 728 6.3 164 1.4 83 0.7 10,615 91.6
Age group
15–24 11,938 298 2.5 85 0.71 20 0.2 11,535 96.6
25–34 9,112 259 2.8 63 0.69 24 0.3 8,766 96.2
35–44 8,241 322 3.9 68 0.83 34 0.4 7,817 94.9
45–54 7,162 381 5.3 50 0.70 45 0.6 6,686 93.4
55–64 5,513 487 8.8 51 0.93 37 0.7 4,938 89.6
≥65 4,723 503 10.7 40 0.85 48 1.0 4,132 87.5
Sex
Male 20,893 1,301 6.2 222 1.06 128 0.6 19,240 92.1
Female 25,796 942 3.6 135 0.52 80 0.3 24,634 95.5
Civil status
Single 13,051 412 3.2 97 0.7 28 0.2 12,514 95.9
Married 22,265 1,216 5.5 187 0.8 113 0.5 20,794 93.4
Currently living-in 7,101 288 4.1 43 0.6 30 0.4 6,740 94.9
Widowed/divorced 4,272 334 7.8 30 0.7 37 0.9 3,871 90.6
Urban/rural classification
Urban 21,526 1,054 4.9 135 0.63 83 0.4 20,254 94.1
Rural 25,163 1,196 4.8 222 0.88 125 0.5 23,620 93.9
Total 46,689 2,250 4.8 357 0.8 208 0.4 43,874 94.0
a
May include symptoms other than the screening symptoms; i.e., fever, night sweats, and/or weight loss
b
Row percentage

49
 Table 10. Socio-demographic characteristics of survey participants who had screening symptoms, 2016 NTPS, Philippines,
(N=46,689)

With screening symptoms

Total survey
Cough ≥2 weeks Cough ≥2 weeks & No symptomsa
Characteristics participants Hemoptysis only
only hemoptysis
No. No. %b No. %b No. %b No. %b
Highest educational attainment
No schooling 855 119 13.9 20 2.3 28 3.3 688 80.5
Pre-elem./elementary 15,178 1,061 7.0 168 1.1 112 0.7 13,837 91.2
High school 18,304 739 4.0 109 0.6 55 0.3 17,401 95.1
Vocational 2,451 82 3.4 11 0.5 2 0.1 2,356 96.1
College/postgraduate 9,821 248 2.5 48 0.5 11 0.1 9,514 96.9
Work status
Employed 21,866 1,148 5.3 202 0.9 117 0.5 20,399 93.3
Unemployed 19,356 975 5.0 123 0.6 85 0.4 18,173 93.9
Student 5,467 127 2.3 32 0.6 6 0.1 5,302 97.0
With health insurance
Yes 29,975 1,492 5.0 223 0.7 138 0.5 28,122 93.8
No 16,194 741 4.6 130 0.8 67 0.4 15,256 94.2
No data 347 11 3.2 3 0.9 1 0.3 332 95.7
Don't know 173 6 3.5 1 0.6 2 1.2 164 94.8
Total 46,689 2,250 4.8 357 0.8 208 0.4 43,874 94.0
a May include symptoms other than the screening symptoms; i.e., fever, night sweats, and/or weight loss
b Row percentage

50
 Table 11. Occupation of survey participants who had screening symptoms, 2016 NTPS, Philippines (N=46,689)

With screening symptoms

Total survey
Cough ≥2 weeks Cough ≥2 weeks & No symptomsa
Occupation participants Hemoptysis only
only hemoptysis
No. No. %b No. %b No. %b No. %b
Without formal 8,819 614 7.0 70 0.8 54 0.6 8,081 91.6
employment
Housewife 10,615 362 3.4 53 0.5 31 0.3 10,169 95.8
Student 5,467 127 2.3 32 0.6 6 0.1 5,302 97.0
Sales/Service 8,623 423 4.9 61 0.7 32 0.4 8,107 94.0
Managers 4,004 186 4.6 29 0.7 18 0.4 3,771 94.2
Agriculture/ forestry/
3,832 318 8.3 63 1.6 51 1.3 3,400 88.7
fishery
Laborer 2,940 166 5.6 33 1.1 15 0.5 2,726 92.7
Professionals and
associate 1,359 32 2.4 7 0.5 0 0.0 1,320 97.1
professionals
Clerks 364 4 1.1 2 0.5 0 0.0 358 98.4
Trades 357 8 2.2 3 0.8 1 0.3 345 96.6
Plant/machine operator
174 3 1.7 3 1.7 0 0.0 168 96.6
or assembler
Others 135 7 5.2 1 0.7 0 0.0 127 94.1
Total 46,689 2,250 4.8 357 0.8 208 0.4 43,874 94.0
a May include symptoms other than the screening symptoms; i.e., fever, night sweats, and/or weight loss
b Row percentage

51
5.1.4. Chest X-ray screening

Participation for chest X-ray examination

A total of 41,444 (88%) out of the survey participants consented to have a chest X-ray
done during the survey (Table 14). Consent to participate was generally similar across
various socio-demographic characteristics, except for a slightly lower participation
among those from stratum 1 (86.9%), age group 25–34 years (85.4%), urban clusters
(86.0%), and those with higher educational attainment (college/postgraduate−83.1%).
Participants who reported any symptoms were nine times more likely to consent to a
chest X-ray.

Three hundred seventy-eight (7.2%) of the 5,245 participants without a chest X-ray
initially gave consent for the procedure but did not show up in the chest X-ray station.
Of these, 297 (78.6%) were interviewed at home, while 81 (21.4%) were interviewed
on-site and went home without having a chest X-ray done. Some of the individuals
may have left because of long waiting times, prior appointments, or breakdown of the
X-ray machine.

Only 1,208 out of 5,245 (or 23%) provided specific reasons for not having a chest X-
ray. Majority of participants without a chest X-ray declined due to pregnancy (77%).
There was no information on 17 participants who did not have a chest X-ray (Table
15).

Among the 5,079 individuals who had no screening symptoms and did not have a
chest X-ray taken, there were more females than males, and majority were between
15 and 34 years of age (Table 16).

52
 Table 12. Distribution of survey participants by chest X-ray status and socio-demographic
characteristics, 2016 NTPS, Philippines (N=46,689)

Chest X-ray
Chest X-ray done Total
Characteristics not done
No. %a No. %a No. %b
Stratum
1 13,952 86.9 2,096 13.1 16,048 34.4
2 8,263 88.4 1,085 11.6 9,348 20.0
3 8,815 90.8 888 9.2 9,703 20.8
4 10,414 89.9 1,176 10.1 11,590 24.8
Age group (years)
15–24 10,439 87.4 1,499 12.6 11,938 25.6
25–34 7,779 85.4 1,333 14.6 9,112 19.5
35–44 7,365 89.4 876 10.6 8,241 17.7
45–54 6,576 91.8 586 8.2 7,162 15.3
55–64 5,085 92.2 428 7.8 5,513 11.8
≥65 4,200 88.9 523 11.1 4,723 10.1
Sex
Male 18,738 89.7 2,155 10.3 20,893 44.7
Female 22,706 88.0 3,090 12.0 25,796 55.3
Urban/rural classification
Urban 18,521 86.0 3,005 14.0 21,526 46.1
Rural 22,923 91.1 2,240 8.9 25,163 53.9
Highest educational attainment
No schooling 746 87.3 109 12.7 855 1.8
Pre-elementary/elementary 14,017 92.4 1,161 7.6 15,178 32.5
High School 16,336 89.2 1,968 10.8 18,304 39.2
Vocational 2,121 86.5 330 13.5 2,451 5.2
College/Postgraduate 8,224 83.1 1,677 16.9 9,901 21.2
Total 41,444c 88.8 5,245 11.2 46,689 100.0
a
Row percentage
b
Column percentage
c
Includes 4 poor chest X-ray images

Table 13. Reasons for not having a chest X-ray takena, 2016
NTPS, Philippines (N=5,245)

Reasons No. %
Pregnant 930 77.0
On wheelchair/bedridden 110 9.1
Recent chest X-ray 85 7.0
Person with disability (PWD) 34 2.8
Illness/mental health problem 11 0.9
Difficulty in ambulation 29 2.4
X-ray malfunction 8 0.7
Lactating 1 0.1
Total 1,208 100.0
a
Only 1,208 participants gave specific reasons; no information on 17 participants

53
 Table 14. Distribution of participants without screening symptoms and
without a chest X-ray, by sex and age, 2016 NTPS, Philippines
(N=5,079)

Age group Male Female Total

(years) No. % a
No. %a No. %a
15–24 549 26.5 920 30.6 1,469 28.9
25–34 474 22.9 828 27.5 1,302 25.6
35–44 375 18.1 478 15.9 853 16.8
45–54 305 14.7 268 8.9 573 11.3
55–64 198 9.6 212 7.0 410 8.1
≥65 168 8.1 304 10.1 472 9.3
Totalb 2,069 40.7 3,010 59.3 5,079 100.0
a Column percentage
b Percentage over total survey participants without symptoms and without a chest X-ray

Field chest X-ray reading results

Table 17 shows the results of the chest X-ray readings by the field team leaders and
the off-site radiologists. Twenty-nine percent chest X-rays taken (12,146 out of 41,443)
were read as suspicious for TB by a field team leader, an off-site radiologist, or both.
Across strata, the lowest proportion of chest X-rays suspicious for TB was in stratum
2 (23.4%) (P<0.0001). Most of the participants with chest X-rays suspicious for TB
were either males (33.9%) (P<0.0001), in the age group ≥65 years (P<0.0001), or
residing in urban clusters (P<0.0001).

Inter-observer agreements among chest X-ray readers

Reading of the chest X-ray films was done during the field survey by both the field
team leaders of the teams and the off-site radiologists assigned to specific clusters.
The digital images were transmitted via internet to the off-site radiologist for verification
of the field team leader’s initial readings. Overall, the agreement between the reading
of the field team leaders and the off-site radiologists was 82.7%, with a kappa value
of only 0.48, suggesting moderate agreement beyond chance.

54
 Table 15. Distribution of chest X-ray reading by the field team leaders and/or
off-site radiologists, by demographic characteristics, 2016 NTPS,
Philippines (N=41,443)

Not
Suspicious for
Suspicious Total
Characteristics TB
for TB
No. %a No. %a No. %b
Stratum
1 9,673 69.3 4,278 30.7 13,951 33.7
2 6,327 76.6 1,936 23.4 8,263 19.9
3 6,111 69.3 2,704 30.7 8,815 21.3
4 7,186 69.0 3,228 31.0 10,414 25.1
Age group (years)
15–24 9,380 89.9 1,059 10.1 10,439 25.2
25–34 6,321 81.3 1,458 18.7 7,779 18.8
35–44 5,281 71.7 2,083 28.3 7,364 17.8
45–54 4,178 63.5 2,398 36.5 6,576 15.9
55–64 2,584 50.8 2,501 49.2 5,085 12.3
≥65 1,553 37.0 2,647 63.0 4,200 10.1
Sex
Male 12,386 66.1 6,352 33.9 18,738 45.2
Female 16,911 74.5 5,794 25.5 22,705 54.8
Urban/rural classification
Urban 12,676 68.4 5,844 31.6 18,520 44.7
Rural 16,621 72.5 6,302 27.5 22,923 55.3
Total 29,297 70.7 12,146 29.3 41,443 100.0
Overall percentage suspicious for TBc: 26.0
a Row percentage
b Percentage calculated over total chest X-rays done
c Percentage calculated over total survey participants

There were 20,365 chest X-ray images read by the central radiologists as per survey
protocol. Agreements between the readings of the field team leaders, off-site
radiologists, and the central radiologists were also determined. The inter-observer
agreement between the field team leaders and the central radiologists was 61.8%
(kappa=0.24) while that between the off-site radiologists and the central radiologists
was 66% (kappa=0.33) (Table 18). Specifically, the field team leaders missed 35.8%
(3,699 out of 10,329) chest X-rays read by the central radiologist as suspicious for TB
(false-negative rate), but over-read 40.6% (4,072 out of 10,035) chest X-rays not read
as suspicious for TB by the central radiologist (false-positive rate).

Comparing field team leader and/or off-site radiologist readings with the central
radiologists, the observed agreement was 62.9% (kappa=0.256), suggesting fair inter-

55
observer agreement in the chest X-ray readings (Table 18). Specifically, the false-
negative rate for the combined readings of the field team leaders and/or the off-site
radiologists compared to the central radiologists was 27.8% (2,877 out of 10,329 chest
X-rays read as suspicious for TB by the central radiologist), while the false-positive
rate was 46.6% (4,675 out of read 10,036 chest X-rays read as not suspicious for TB
by the central radiologist).

Table 16. Inter-observer agreements for chest X-ray readings by different

sets of readers, 2016 NTPS, Philippines

No. of chest Kappa value

Readers Agreement
X-rays (95% CI)
Field team leaders vs. off-site
41,441 82.7% 0.48 (0.47–0.49)
radiologists
Field team leaders vs. central
20,364 61.8% 0.24 (0.22–0.25)
radiologists
Off-site radiologists vs. central
20,365 66.4% 0.33 (0.32–0.34)
radiologists
Field team leader and/or off-site
radiologists vs. central 20,365 62.9% 0.256 (0.255–0.259)
radiologists

The fairly low inter-observer agreements and kappa values among the different
readers may be attributed to the difference in reading conditions in the field and the
short turn-around time for the field team leaders and the off-site radiologists to read
the X-ray images prior to deciding on sputum eligibility. In addition, the field team
leaders were instructed to “over-read” chest X-rays when in doubt so as not to miss
potential PTB cases who would be asked to provide sputum samples.

Central chest X-ray findings

There were 20,365 chest X-rays read by the central radiologists as per protocol, of
which 10,329 (50.7%) were suspicious for TB; 4,227 (20.8%) with abnormalities not
suspicious for TB; and 5,809 (28.5%) read as normal. Of the 10,329 chest X-rays
suspicious for TB, 10,005 (96.9%) had fibrohazy or reticular densities. Nodular lesions
were seen in 834 chest X-ray images (8.1%). New calcifications were seen in 409
images (4.0%), while cavities were noted in 230 images (2.2%). Airway deviations
were seen in 1,051 X-rays (10.2%).

It should be noted that none of the above lesions are specific for diagnosing PTB.
Fibrohazy and reticular densities are seen in pneumoconiosis and airspace diseases.

56
Calcifications generally indicate previous infection or inflammation. Nodules may be
indicative of infections or neoplasms. Cavities are also seen in nontuberculous
mycobacterial infections or granulomatous fungal infections. Airway deviations are
seen with any condition that causes pulmonary scarring.

The most common location of lesions according to readings from the central
radiologists was in the right apex (42.7%), followed by the left apex (36.7%). Both
apices had lesions in 31.3% of abnormal X-rays. Multiple lesions were seen in 36.7%
of abnormal X-rays.

5.1.5. Sputum eligibility by screening symptoms and chest X-ray

Out of the 46,689 survey participants, 18,597 (39.8%) were positively screened
through symptom screening, chest X-ray findings, or both (Table 19). Screening by
chest X-ray findings alone detected the biggest proportion of sputum-eligible
individuals at 22.9% (10,702 of 46,689). In contrast, only 3.1% of the survey
participants (1,457 of 46,689) were eligible for sputum examination based on the
presence of screening symptoms alone. Only 2.9% (1,358 out of 46,689) had both
screening symptoms and chest X-ray findings consistent with PTB. Sputum samples
from 10.9% (5,080 of 46,689) of the participants were collected because although they
had no screening symptoms, a chest X-ray was not done.

Of the 10,702 participants who were eligible for sputum collection based on findings
on positive chest X-ray findings alone, majority (54.6%) had none of the non-specific
symptoms i.e. fever, weight loss, night sweats and cough <14 days duration (Table
20). Among those who did have non-specific symptoms as covered by the field
questionnaire, the most common symptom was cough <14 days duration (Table 20).

57
 Table 17. Results of screening based on symptoms and field chest X-ray
results, 2016 NTPS, Philippines (N=46,689)

Total participants
Total survey Total sputum-
Screening Chest X-ray who submitted
participants eligible
symptomsa readingb sputum
No. No. %c No. %d
Positive Positive 1,358 1,358 2.9 1,348 99.3
Positive Negative 1,291 1,291 2.8 1,189 92.1
Positive Not done 166 166 0.4 156 94.0
Negative Positive 9,359 9,359 20.0 9,203 98.3
Negative Positive chest X- 1,343 1,343 2.9 851 63.4
ray reading by
the off-site
radiologists
Negative Poor X-ray image 1 1 0.0 1 100.0
Negative Negative 28,092 0 0.0 0 0.0
Negative Not done 5,079 5,079 10.9 3,494 68.8
Total 46,689 18,597 39.8 16,242 87.3
a Self-reported TB symptom screening included ≥2 weeks’ cough and/or hemoptysis.
b Chest X-ray reading by the field team leader and/or off-site radiologist.
c Percentage calculated over total survey participants
d Percentage calculated over sputum-eligible participants
e Participants were recalled to the survey site for sputum collection if the chest X-ray was read as not suspicious

for TB by the field team leader but was read by the off-site radiologist otherwise.

Table 18. Distribution of non-specific symptoms among survey participants

positively screened for TB based on field chest X-ray findings only,
2016 NTPS, Philippines (N=10,702)

Sputum-eligible participants
Non-specific symptoms
Male Female Total
(combinations)
No. No. No. %a
Fever only 213 187 400 3.7
Weight loss only 562 593 1,155 10.8
Night sweats only 156 135 291 2.7
Cough <14 days duration only 835 715 1,550 14.5
With any 2 of the above symptoms 569 525 1,094 10.2
With ≥3 of the above symptoms 203 162 365 3.4
No other symptoms 2,890 2,957 5,847 54.6
Total 5,428 5,274 10,702 100.0
a Column percentage

58
On the other hand, there were 5,080 individuals (10.9% of all the survey participants)
who did not have symptoms and did not have chest X-rays taken.6 In the absence of
a chest X-ray, they were also considered sputum-eligible in spite of the absence of
screening symptoms. Among these, the majority (67.8%) did not have any of the non-
specific symptoms. The most frequently reported symptoms were weight loss and
cough <14 days duration (Table 21).

Table 19. Distribution of non-specific symptoms among sputum-eligible

participants without screening symptoms and without chest X-
rays, 2016 NTPS, Philippines (N=5,080)

Sputum-eligible participants
Non-specific symptoms Male Female Total
(combinations)
No. No. No. %a
Fever only 72 93 165 3.2
Weight loss only 186 303 489 9.6
Night sweats only 50 110 160 3.1
Cough <14 days duration only 197 254 451 8.9
With any 2 of the above symptoms 116 184 300 5.9
With ≥3 of the above symptoms 31 40 71 1.4
No other symptoms 1,417 2,027 3,444 67.8
Total 2,069 3,011 5,080b 100.0
a Column percentage
b Includes 1 poor X-ray image

A total of 28,092 individuals (60.2% of all survey participants) had no screening

symptoms and no findings on X-ray consistent with TB and were therefore not eligible
for sputum collection. Non-specific symptoms (Table 22) were absent in the majority
(61.8%). Cough of <2 weeks duration was the most frequently reported non-specific
symptom (11.3%), followed by weight loss (9.6%). Only 10% reported ≥2 symptoms.

6 One of the 5,080 participants did have a chest X-ray done but the image was not read because of poor image
quality.

59
 Table 20. Distribution of non-specific symptoms among participants who
were not sputum-eligible, 2016 NTPS, Philippines (N=28,092)

Sputum-ineligible
Non-specific symptoms
Male Female Total
(combinations)
No. No. No. %a
Fever only 534 660 1,194 4.3
Weight loss only 1,078 1,606 2,684 9.6
Night sweats only 353 523 876 3.1
Cough <14 days duration only 1,506 1,664 3,170 11.3
With any 2 of the above symptoms 1,000 1,199 2,199 7.8
With ≥3 of the above symptoms 282 325 607 2.2
No other symptoms 6,990 10,372 17,362 61.8
Total 11,743 16,349 28,092 100.0
a Column percentage

5.1.6. Sputum collection

A total 16,242 sputum-eligible participants were able to give at least one sputum
specimen (Table 23). Among those with screening symptoms, 2,693 (95.7%)
submitted sputum specimens. The proportions submitting sputum among males and
females were similar (87.0% and 87.7%, respectively). In terms of age groups, there
were significantly more individuals in the older age groups (≥45 years) who provided
sputum specimens (P<0.0001).

Table 21. Distribution of sputum-eligible participants and sputum collection

status by sex and age group, 2016 NTPS, Philippines (N=18,597)

Total sputum-eligible Total sputum-collected

Characteristics
No. %a No. %b
Sex
Male 9,150 49.2 7,956 87.0
Female 9,447 50.8 8,286 87.7
Age group (years)
15─24 2,852 15.3 2,297 80.5
25─34 2,992 16.1 2,475 82.7
35─44 3,188 17.1 2,733 85.7
45─54 3,157 17.0 2,811 89.0
55─64 3,120 16.8 2,859 91.6
≥65 3,288 17.7 3,067 93.3
Total 18,597 100.0 16,242 87.3
a Column percentage
b Row percentage

60
The sputum collection rates were above 90% for participants who were positive for
screening symptoms and also for individuals who had no symptoms and only had
chest X-ray findings consistent with PTB. The sputum collection rate was low (63.4%)
for participants who did not have symptoms and whose chest X-ray was initially read
as normal by the field team leader (2.9% of all sputum-eligible participants). Similarly,
the sputum collection rate was low (68.8%) for participants who had no symptoms and
who did not undergo chest X-ray (Table 19).

Among the sputum-eligible participants, the percentage of sputum collection was

highest in stratum 3 (92.5%), followed by stratum 4 (89.8%), stratum 1 (86.2%), and
stratum 2 (79.8%) (Table 24). In terms of actual specimens, the number of sputum
samples collected was highest in stratum 1 followed by stratum 4.

Table 22. Distribution of sputum-eligible participants by stratum and sputum

collection status, 2016 NTPS, Philippines (N=18,597)

Total sputum-eligible Total sputum collected

Stratum
No. %a No. %b
1 6,676 35.9 5,754 86.2
2 3,220 17.3 2,570 79.8
3 3,853 20.7 3,564 92.5
4 4,848 26.1 4,354 89.8
Total 18,597 100.0 16,242 87.3
a Column percentage
b Percentage over total sputum-eligible

Out of the 18,597 survey participants who were eligible for sputum, 16,242 (87.3%)
submitted at least one spot sputum specimen (S1). There were 15,547 (83.6%) who
provided a second specimen (S2), most of which were morning sputum specimens.
Only 32 (0.7%) submitted a third specimen (S3) (Table 25).

Table 23. Availability of sputum specimens from sputum-eligible survey

participants, 2016 NTPS, Philippines (N=18,597)

Sputum specimens collected

Sputum specimen
No. %
S1 16,242 87.3a
S2 15,547 83.6a
Morning sputum 9,824 63.2
Spot collection 5,723 36.8
S1 and S2 specimens with <3 ml volume 4,597 14.5
S3 among those with<3 ml volume collected 32 0.7b
Total no. of specimens 31,821 100.0
a
Percentage out of 18,597 sputum-eligible participants
b Percentage out of total S1 and S2 with <3 ml volume

61
5.2. Laboratory results

5.2.1. Overall laboratory results

Figure 11 shows a flow diagram of the laboratory results from DSSM, Xpert MTB/RIF,
and culture. A total of 16,058 specimens were processed for DSSM and cultured, while
16,240 were processed for Xpert. Culture was not done in 210 specimens because of
inadequate volume of the sputum specimens; DSSM was not done in 184, and Xpert
MTB/RIF testing was inadvertently not done in 2 specimens. For the majority of
specimens submitted, Xpert MTB/RIF was done on S1 specimens, while DSSM and
culture were done on S2 specimens.

A summary of the laboratory results of sputum specimens processed from the different
laboratories is shown in Table 26. Among all the 16,242 sputum-eligible participants
who submitted sputum, 183 were DSSM-positive (1.1%; range for the six laboratories:
0.4─1.6%); 397 were Xpert-positive (2.5%; range: 1.4─2.8%); 232 were MTB culture-
positive (1.4%; range: 0.6─1.8%); and 520 were NTM culture-positive (3.2%; range:
0.08─6.4%).

MTB was detected by Xpert MTB/RIF in 154 (84%) of the sputum specimens that were
DSSM-positive. MTB grew on culture in 109 (70.8%) of the 154 specimens that were
Xpert-positive and smear-positive. Out of the 154 Xpert-positive, smear-positive
specimens, 6 (3.9%) grew NTM. On the other hand, from the 15,875 participants with
DSSM-negative results, Xpert MTB/RIF was positive in 239 (1.5%). From this group,
the culture grew MTB in 50 (20.9%) and NTM in 6 specimens (2.5%). Since Xpert
MTB/RIF detects only MTB, the NTM growth suggests mixed cultures of MTB and
NTM.

62
Figure 11. Flow diagram of DSSM, Xpert MTB/RIF, and culture results, 2016 NTPS, Philippines

63
 Table 24. Distribution of laboratory results by TB laboratory, 2016 NTPS, Philippines (N=16,032)

DSSM Xpert MTB/RIF Culture

Total
No. of MTB NTM NEG CON
Laboratorya No. No. + No. No. + cultured
clusters
smeared (%) processed (%) No. No. No. No. No.
(%) (%) (%) (%) (%)
NTRL 27 3,981 47 3,990 114 65 132 3,672 102 3,971
(1.2) (2.9) (1.6) (3.3) (92.5) (2.6) (100.0)
MRL 23 2,958 46 3,017 72 54 190 2,684 25 2,953
(1.6) (2.4) (1.8) (6.4) (90.9) (0.8) (100.0)
CTRL 22 3,697 45 3,694 101 56 3 3,571 66 3,696
(1.2) (2.7) (1.5) (0.1) (96.6) (1.8) (100.0)
R2TRL 12 1,584 16 1,658 40 21 67 1,480 8 1,576
(1.0) (2.4) (1.3) (4.3) (93.9) (0.5) (100.0)
DTRL 12 2,043 21 2,046 44 25 61 1,946 11 2,043
(1.0) (2.2) (1.2) (3.0) (95.3) (0.5) (100.0)
NMTRL 10 1,795 8 1,795 26 11 67 1,671 44 1,793
(0.4) (1.4) (0.6) (3.7) (93.2) (2.5) (100.0)
Overall 106 16,058b 183 16,200c 397 232 520 15,024 256 16,032d
(1.1) (2.5) (1.4) (3.2) (93.7) (1.6) (100.0)
a Abbreviations: NTRL: National TB Reference Laboratory; MRL: Medical Research Laboratory, Philippine General Hospital; CTRL: Cebu TB Reference Laboratory;
R2TRL: Region 2 TB Reference Laboratory; DTRL: Davao TB Reference Laboratory; NMTRL: Northern Mindanao TB Reference Laboratory. CON: contaminated
b Did not include 184 specimens not tested for DSSM
c Did not include 40 specimens with Error/Invalid results and 2 not tested for Xpert MTB/RIF
d Did not include 210 specimens not tested for culture

64
5.2.2. DSSM results

In terms of DSSM results, only 0.6% out of the 6,270 spot specimens (S1, spot S2,
and S3) were smear-positive, compared to 1.5% out of 9,788 early morning specimens
(p<0.0001) (Table 27).

Table 25. DSSM results of spot and morning specimens, 2016 NTPS, Philippines
(N=16,242)

Results Total
Specimens number of
Smear- Smear-
Specimen collected but no specimens
positive negative
DSSM used for
No. %a No %a No. %a DSSM
b
S1 8 1.1 537 73.7 184 25.2 729
S2 (spot) 30 0.5 5,678 99.5 0 0.0 5,708
S2
145 1.5c 9,643 98.5 0 0.0 9,788
(morning)
S3 0 0.0 17 100.0 0 0.0 17
Total 183 1.1 15,875 97.7 184 1.1 16,242
a Percentage calculated over total specimen collected
b Note: S1 and S3 are spot specimens per protocol
c Significantly higher yield with morning sputum (1.5%) vs spot specimen (0.6%) (P<0.0001)

Since it was the first time that LED-FM was used by most of the DOH participating
laboratories, particularly for 2016 NTPS, the sensitivity and specificity of DSSM was
determined using the combined results of MTB culture and Xpert MTB/RIF as the
“gold” standard.

The sensitivity of DSSM for MTB using LED-FM was 36.7% (95% CI: 32.3−41.3%),
and the specificity was 99.93% (95% CI: 99.88−99.97%) (Table 28). The positive
predictive value was 94.4% (95% CI: 90.0−97.3%), while the negative predictive value
was 98.1% (95% CI: 97.9−98.3%). Based on a prevalence of 1%, the positive and
negative predictive values are 84.1% and 99.4%, respectively.

65
 Table 26. Sensitivity and specificity of DSSM LED-FM for M. tuberculosis using
combined Xpert MTB/RIF and culture results as gold standard, 2016
NTPS, Philippines (N=15,735)

Combined MTB culture and

Xpert MTB/RIF results
DSSM by LED-FM Total
No. of No. of
positive negative
Positive 169 10 179
Negative 291 15,265 15,556
Total 460 15,275 15,735
Note: Only MTB was considered culture positive; NTM was considered culture negative. For culture results,
contaminated and test not done were not included (n=282). For Xpert results, Error/Invalid and test not done
were not included (n=41). Only those specimens with a complete set of laboratory results are included in
this analysis.
Sensitivity: 36.7% (95% CI: 32.3–41.3%)
Specificity: 99.93% (95% CI: 99.88%–99.97%)
PPV: 94.4% (95% CI: 90.0%–97.3%)
NPV: 98.1% (95% CI: 97.9%–98.3%)

5.2.3. Xpert MTB/RIF results

A total of 397 out of 16,240 (2.4%) specimens were positive for MTB by Xpert
MTB/RIF. Xpert MTB/RIF results were negative in 15,803 (97.3%) specimens. There
were 40 error or invalid results (0.3%).

Comparison of Xpert MTB/RIF and DSSM

As shown in Table 29, 239 (1.5%) of the 15,875 smear-negatives were Xpert-positive.
Of the 15,665 Xpert-negative specimens that were smeared, only 29 were smear-
positive. A statistically significant but modest correlation was found between the
degree of Xpert positivity and the grading of DSSM results (Spearman ρ=0.6,
P<0.0001).

Not surprisingly, even in specimens with scanty DSSM readings, Xpert still detected
MTB. What was notable was that in the DSSM group with findings of scanty AFB,
Xpert detected the highest percentage of positive specimens (17.4%). On the other
hand, there were decreasing trends in Xpert positivity compared to DSSM slides that
were read as 1+, 2+, and 3+ (9.8%, 7.6%, and 4% Xpert positivity, respectively).

66
 Table 27. Comparison of Xpert MTB/RIF and DSSM results, 2016 NTPS,
Philippines (N=16,242)

DSSM results
Xpert results
No. No. No. No. No. No. No. Total
negative scanty 1+ 2+ 3+ not done No.
Not detected 15,636 21 4 2 2 180 15,845
Detected 239 69 39 30 16 4 397
Very Low 130 17 3 2 1 1 154
Low 94 34 12 1 4 2 147
Medium 15 17 21 19 5 1 78
High 0 1 3 8 6 0 18
Total No. 15,875 90 43 32 18 184 16,242
a Includes 40 error and 2 not done

MTB was detected by Xpert MTB/RIF in 84% of the specimens that were DSSM-
positive. Seventy-one percent of all smear-positive, Xpert-positive specimens grew
MTB on culture. Conversely, 85% of smear-positive, MTB-positive cultures were
Xpert-positive (Table 30). Six out of the 154 Xpert-positive, smear-positive specimens
grew NTM (3.9%).

Table 28. Comparison of Xpert MTB/RIF vs. culture results among

smear-positive specimens, 2016 NTPS, Philippines
(N=183)

Culture results
Xpert results
No. No. No. No. Total
No.
MTB NTM Contaminated Negative No.
Positive 109 6 4 35 154
Negative 19 5 0 5 29
Total No. 128 11 4 40 183
Culture-positive from Xpert-positive specimens = 109/154 = 71%
Xpert-positive from culture-positive specimens = 109/128 = 85%

On the other hand, from among the 15,875 specimens with negative DSSM results,
Xpert was positive in 239 (1.5%). Among this smear-negative, Xpert-positive group,
only 21% grew MTB on culture, while 2.5% grew NTM. Similar to the smear-positive
group, there was a higher percentage of Xpert positivity (48%) among the smear-
negative, MTB-positive cultures (Table 31).

67
 Table 29. Comparison of Xpert vs. culture results among smear-negative specimens

Combined culture results

Xpert results
No. No. No. No. No. Total
No.
MTB NTM Contaminated Negative Not done No.
Positive 50 6 2 181 0 239
Negative 54a 502 250 14,763 26 15,595
Error 0 1 0 38 0 39
Not done 0 0 0 2 0 2
Total No. 104 509 252 14,984 26 15,875
Culture-positive from Xpert-positive specimens = 50/239 = 21%
Xpert-positive from culture-positive specimens = 50/104 = 48%
a
Note: Four cultures with <9 colonies were not considered survey TB cases by the Diagnostic and Medical
Panel after considering all clinical and laboratory parameters.

Comparison of Xpert MTB/RIF and culture

Using all results with available Xpert MTB/RIF and culture results, Table 32 shows that
among Xpert-positive specimens, 159 (40.1%) grew MTB. In contrast, among 232
MTB culture-positive specimens, 159 (68.5%) were Xpert-positive. Twenty-eight of the
216 Xpert-positive, culture-negative specimens (13%) came from participants who
were currently on treatment. Among the 15,803 Xpert-negative specimens, only 0.5%
grew MTB on culture.

Table 30. Comparison of Xpert MTB/RIF vs. culture results, regardless of

DSSM results, 2016 NTPS, Philippines (N=16,242)

Culture results

Xpert MTB/RIF MTB NTM Contaminated Negative Not done Total

results
No. No. No. No. No. No.
(%) (%) (%) (%) (%) (%)
Positive 159 12 6 216 4 397
(40.1) (3.0) (1.5) (54.4) (1.0) (100.0)
Negative 73 507 250 14,768 205 15,803
(0.5) (3.2) (1.6) (93.5) (1.4) (100.0)
Error 0 1 0 38 1 40
(0.0) (2.5) (0.0) (95.0) (2.5) (100.0)
Not done 0 0 0 2 0 2
(0.0) (0.0) (0.0) (100.0) (0.0) (100.0)
Total 232 520 256 15,024 210 16,242

68
5.2.4. Culture results

The success of culture isolation of Mycobacteria sp. from suspected participants would
depend on good quality specimens, proper transport of these specimens to the
laboratory, and maintenance of the cold chain in transit. In the laboratory, processing
of specimens within five days from collection can improve diagnostic yield. Details of
the workload of the six TB laboratories, the characteristics of the specimens in terms
of visual appearance, adequacy of volume, temperature during transport, and time
from collection to testing are provided in Annex C-2.

MTB culture results

In terms of culture positivity, only 62 of 6,250 (1.0%) spot specimens that were cultured
were positive for MTB, compared to 170 out of 9,782 (1.7%) morning specimens
(P<0.0001). (Table 33)

The mycobacterial culture results were quantified based on the number of colonies
observed after eight weeks of incubation. Among those with countable colonies of ≤9,
14.2% grew MTB while 48.8% were NTM. Specimens with growths of 1+, 2+, and 3+
showed higher yields of MTB. For those with 3+ colonies, 28 out of 35 (80%) were
MTB. Even among partially contaminated culture tubes, NTM and MTB were detected.
(Table 34)

69
 Table 31. Distribution of mycobacterial culture results from spot and morning specimens, 2016 NTPS, Philippines (N=16,242)

Culture results
Specimen collected Total no. of
Negative for both specimens
Specimen MTB NTM Contaminated but culture not
MTB and NTM
done
No. %a No. %a No. %a No. %a No. %a
S1 (spot) 10 1.4 12 1.6 496 67.2 10 1.4 210b 28.5 738
S2 (spot) 52 0.9 135 2.4 5,422 95.0 96 1.7 0 0.0 5,705
S2 (morning) 170 1.7c 373 3.8 9,089 92.9 150 1.5 0 0.0 9,782
S3 0 0.0 0 0.0 17 100.0 0 0.0 0 0.0 17
Total 232 1.4 520 3.2 15,024 92.5 256 1.6 210 1.3 16,242
a Row percentage
b Submitted S1 only, except for two participants who submitted spot S2 and one participant who submitted 1 morning S2.
c Significantly higher yield with morning sputum (1.7%) vs spot specimen (1.0%) (P< .0001)

70
 Table 32. Culture results by colony count, 2016 NTPS, Philippines (N=16,242)

Culture results
Laboratory
result MTB NTM CONa Negative Not done Total
No. (%b) No. (%b) No. (%b) No. (%b) No. (%b) No.
No growth 0 (0.0) 0 (0.0) 0 (0.0) 14,608 (100.0) 0 (0.0) 14,608
1─9 colonies 109 (14.2) 375 (48.8) 0 (0.0) 284 (37.0) 0 (0.0) 768
1+ 66 (30.8) 117 (54.7) 0 (0.0) 31 (14.5) 0 (0.0) 214
2+ 27 (56.3) 15 (31.2) 0 (0.0) 6 (12.5) 0 (0.0) 48
3+ 28 (80.0) 6 (17.1) 0 (0.0) 1 (2.9) 0 (0.0) 35
Partially CON 2 (1.8) 7 (6.4) 6 (5.5) 94 (86.2) 0 (0.0) 109
No data 0 (0.0) 0 (0.0) 250 (54.3) 0 (0.0) 210 (45.7) 460
Total 232 . 520 . 256 . 15,024 . 210 . 16,242
a CON: Contaminated
b Row percentages

Comparison of culture and DSSM

As shown in Table 35, 104 (0.66%) of the 15,849 smear-negative specimens were
MTB culture positive while 509 (3.2%) grew NTM. On the other hand, of the 15,024
culture-negative specimens that were smeared, 40 (0.3%) were smear-positive.
Negative and scanty DSSM readings tended to have weakly positive cultures (0─9
colonies) or 1+ colony counts. Those with higher DSSM counts of 2+ or 3+ tended to
have higher colony counts on culture.

Table 33. Comparison of culture and DSSM results, 2016 NTPS, Philippines (N=16,242)

DSSM results
No. of colonies on No. No. No. No. No. No. Total
culture negative Scanty 1+ 2+ 3+ not done No.
No growth 14,984 30 7 1 2 0 15,024
0─9 84 16 8 3 0 0 111
1+ 18 25 13 8 2 0 66
2+ 2 7 6 7 5 0 27
3+ 0 2 7 11 8 0 28
NTM 509 8 1 1 1 0 520
CON 252 2 1 1 0 0 256
Not done 26 0 0 0 0 184 210
Total No. 15,875 90 43 32 18 184 16,242

71
 Drug-resistant TB

Out of 397 Xpert MTB-positive specimens, rifampicin resistance was detected in 29

(7.3%), compared to the rifampicin resistance rate from standard DST from culture,
which was 5.7%. Three of the 29 (10.3%) rifampicin-resistant MTB by Xpert MTB/RIF
were susceptible by DST (Table 36).

Table 34. Comparison of rifampicin resistance detected by Xpert MTB/RIF

and DST results, 2016 NTPS, Philippines (N=16,242)

DST result No.

No.
Xpert MTB/RIF culture
No. RIF No. RIF No. DST culture
result not
susceptible resistant not done negative
done
MTB detected RIF
resistance 3 10 0 15 1
detected
MTB detected
RIF resistance not 146 0 0 209 3
detected
MTB detected
RIF resistance 0 0 0 10 0
indeterminate
MTB not detected 68 3 2 15,525 205
Error/Invalid 0 0 0 39 1
Not done 0 0 0 2 0
Total 217 13 2 15,800 210

Of the 232 MTB culture-positive isolates, 3 were not recovered on subcultures and
only 229 were processed for DST using the Proportion method in 91.8% and the Line
Probe Assay in 7.8%. There were 190 isolates (83%) fully susceptible to the first- and
second-line drugs. Isoniazid mono-resistance was 5.6%. Any type of rifampicin
resistance by DST of 229 isolates was 5.7% (13 isolates), of which MDR-TB (RIF+INH)
accounted for 3.9% (9 isolates) (Table 37).

72
 Table 35. Distribution of drug susceptibility test results among those with
positive TB culture results, 2016 NTPS, Philippines (N=232)

Drug susceptibility results No. %

Fully susceptible to first line and second line drugs 190 82.9
Rifampicin-resistant
Rifampicin 4 1.7
Rifampicin and isoniazid 5 2.2
Rifampicin, isoniazid and streptomycin 1 0.4
Rifampicin, isoniazid, ethambutol and streptomycin 0 0.0
Rifampicin, isoniazid, ethambutol and streptomycin + levofloxacin 3 1.3
Mono-resistant
Isoniazid 13 5.6
Ethambutol 0 0.0
Streptomycin 7 3.0
Kanamycin 0 0.0
Capreomycin 0 0.0
Amikacin 0 0.0
Levofloxacin 0 0.0
Fluoroquinolones (LPA) 0 0.0
Aminoglycosides (LPA) 0 0.0
Poly-resistant
Isoniazid and streptomycin 6 2.6
Non-viable/DST not done 3 1.3
Total 232 100.0

5.2.5. Laboratory quality assurance

In general, the six laboratories that received and processed specimens for the survey
performed reliably, based on the quarterly visits by the QM-Laboratory team (Table
38). The overall recovery rate for Mycobacteria sp. and specifically for MTB was 89%
and 85.7%, respectively, which were within acceptable standards. Only one laboratory
did not meet the desired 80─90% quality performance indicator in terms of recovery
rates for Mycobacteria sp. and MTB. The other overall performance indicators were
within quality standards, except for the proportion of smear-positive specimens that
were culture-negative (Table 38). However, if patients on current treatment were
excluded from the analysis, the overall smear-positive, culture-negative rate would be
2.2%. Four of the six laboratories were within the limits of acceptable contamination
rates.

73
 Table 36. Performance quality indicators for the six participating TB laboratories, 2016 NTPS, Philippinesa

Performance QA
NTRL MRL CTRL R2TRL DTRL NMTRL OVERALL
indicators threshold
Recovery rate for
Mycobacteria sp. 81/91b
No. smear + culture + / 80─90% 23/24 17/20 19/23 7/8 12/12 3/4
No. of total smear + (95.8) (85.0) (82.6) (87.5) (100.0) (75.0) (89.0)
(% culture + among
smear +)
Recovery rate for
MTB 78/91
No. smear + MTB culture 80─90% 22/24 17/20 18/23 7/8 11/12 3/4
+ / No. of total smear + (91.7) (85.0) (78.3) (87.5) (91.7) (75.0) (85.7)c
(% MTB culture + among
smear +)
No. smear - culture +
/ No. of total smear - 174/3,852 227/2,912 40/3,610 81/1,562 74/2,019 75/1,770 671/15,728
<20%
(% smear - that are (4.5) (7.8) (1.1) (5.2) (3.7) (4.2) (4.3)
culture +)
No. smear + culture -
/ No. of total smear + 1/24 3/20 4/23 1/8 0/12 1/4 10/91
<10%
(% smear + that are (4.2) (15.0) (17.4) (12.5) (0.0) (25.0) (11.0)d
culture -)
Contamination rate
381/7,958 156/5,914 420/7,398 44/3,158 82/4,090 227/3,636 1,310/32,152
No. contaminated tube / 2─5%
No. cultured (4.8) (2.6) (5.7) (1.4) (2.0) (6.2) (4.1)
(% contamination)
No. invalid/error on
repeat / No. of total 0/3,999 3/3,024 14/3,711 19/1,679 4/2,053 0/1,820 40/16,286
<3%
Xpert tested (0.0) (0.1) (0.4) (1.1) (0.2) (0.0) (0.2%)
(% invalid/error)
a
NTRL: National TB Reference Laboratory; MRL: Medical Research Laboratory, Philippine General Hospital; CTRL: Cebu TB Reference Laboratory;
R2TRL: Region 2 TB Reference Laboratory; DTRL: Davao TB Reference Laboratory; NMTRL: Northern Mindanao TB Reference Laboratory
b Recovery rate for Mycobacteria sp. when 8 survey participants currently on treatment are excluded from the denominator: 81/83 = 97.6%
c Recovery rate for MTB when 8 survey participants currently on treatment are excluded from the denominator: 78/83 = 94.0%
d % smear + that are culture - when survey participants currently on treatment are excluded from the denominator: 2/91 = 2.2%

74
5.3. Bacteriologically confirmed PTB cases

5.3.1. TB case classification by the Diagnostic and Medical panel

The Diagnostic and Medical Panel reviewed the laboratory results, chest X-ray
findings and symptoms of 470 participants with bacteriologically confirmed results. The
Xpert MTB/RIF and MTB culture results of the 470 were: 238 positive by Xpert
MTB/RIF alone; 73 positive on MTB culture alone; and 159 positive by both Xpert
MTB/RIF and MTB culture.

Using the survey case classification matrix, the Diagnostic and Medical Panel
categorized the 470 participants based on results of Xpert, DSSM, culture tests, and
X-ray reading by the central radiologists (Table 39). The panel classified 466 as
bacteriologically confirmed PTB prevalent cases. Four participants with weak culture
results (i.e., only 1─9 colonies), Xpert-negative and smear-negative, and chest X-rays
not suggestive of TB or not done were classified as non-cases.

Table 40 provides a breakdown of the case classification of the 466 BCTB cases by
DSSM result. There were 289 (62%) smear-negative BCTB cases, of which 189 (41%)
were Xpert-positive only. There were only 173 (37.1%) smear-positive TB cases; 109
(23.3%) were TB culture-positive and Xpert-positive. Using the survey case definitions,
238 (51.1%) were Xpert-positive only, 159 (34.1%) were Xpert-positive and culture-
positive, and 69 (14.8%) were culture-positive only.

75
 Table 37. Case classification of 470 survey participants with bacteriologically
confirmed results, 2016 NTPS, Philippines

Xpert
DSSM Culture CXR central Survey case
MTB/RIF Categorya No.
result MTB reading classification
result
Positive
Positive Any Case S+B+ 109
(any)
Positive Not positiveb Any Case S+B+ 45
Positive
Positive
(n=397) Negative Any Case S-B+ 50
(any)

Negative Not positiveb Any Case S-B+ 189

NDa NDa Any Case S?B+a 4

Positive
Positive Any Case S+B+ 19
(any)
Negative
Positive
(n=69) Negative Any Case S-B+ 7
strong c
Positive
Negative Suggestive Case S-B+ 43
weak d
Total bacteriologically confirmed PTB cases 466
Positive Normal/not
Negative Non-case S-B+ 2
Negative weak d suggestive
Positive
Negative NA Non-case S-B+ 2
weak d
Not classified as TB cases 4
a S: smear result; B: bacteriological results from Xpert and/or MTB culture; ND: not done; S?: smear
not done
b Negative culture or contaminated
c Strong: 10 or more colonies on culture
d Weak: 1−9 colonies on culture

Table 38. Classification of survey TB cases, 2016 NTPS, Philippines (N=466)

Survey TB cases No. %

Smear-positive 173 37.1
MTB culture-positive and Xpert-positive 109 23.4
MTB culture-positive and Xpert-negative 19 4.1
MTB culture-negative and Xpert-positive 45 9.7
Smear-negative 289 62.0
MTB culture-positive and Xpert-positive 50 10.7
MTB culture-positive and Xpert-negative 50 10.7
MTB culture-negative and Xpert-positive 189 40.6
Smear and MTB culture (not done) and Xpert positive 4 0.9
Total 466 100.0

76
5.3.2. Symptoms and chest X-ray findings among survey cases

Only a third (32%) of the survey cases reported having a cough of ≥2 weeks and/or
hemoptysis. Most of the survey cases (42%) did not report symptoms suggestive of
TB but had other non-specific symptoms: cough <14 days with or without fever, weight
loss or night sweats (26%), or no cough but with either fever, weight loss or night
sweats (15%). There were 26% of the survey cases who did not report any of the
above symptoms (Table 41).

Table 39. Distribution of symptoms of the sputum-eligible population

according to self-reported screening symptoms, 2016 NTPS,
Philippines (N=46,689)

Total Survey cases Non-cases

Symptoms participants (n=466) (n=15,775)
No. No. %a No. %a
Screening symptoms
positiveb 2,809 150 32.2 2,537 16.1
Cough ≥14 days only 2,244 117 25.1 2,036 12.9
Hemoptysis only 212 5 1.1 188 1.2
Cough ≥14 days and
hemoptysis 208 22 4.7 176 1.1
Cough <14 days and
hemoptysis 145 6 1.3 137 0.9
Screening symptoms
negative but with other
symptoms 17,221 195 41.8 5,636 35.7
Cough <14 daysc 8,068 124 26.6 2,802 17.8
No coughd 9,153 71 15.2 2,834 18.0
Symptom positive,
unspecifiede 6 0 0.0 6 0.0
No symptoms 26,653 121 26.0 7,596 48.2
TOTAL 46,689 466 100.0 15,775 100.0
a
Column percentage
b Screening symptoms: cough ≥14 days and/or hemoptysis
c With or without weight loss, fever, and /or night sweats
d Symptoms may include weight loss, fever and/or night sweats
e Symptom positive, unspecified: with screening symptoms, but not specified whether cough ≥14 days or

hemoptysis

Table 42 shows the distribution of smear-positive and survey cases based on

screening symptoms and chest X-ray findings. Of the 173 smear-positive cases, 88
(51%) were positive by screening symptoms and 127 (73%) reported cough of any
duration. Among the 466 survey cases, 150 (32%) were positive by screening
symptoms and 269 (58%) reported cough of any duration.

77
Among the survey cases, 92.3% had chest X-rays suggestive of TB based on initial
reading by the field team leader and/or off-site radiologist. Among those survey cases
with X-ray findings suggestive of TB, the majority were negative for screening
symptoms (63.9%). Only 132 (28%) of the survey cases were positive by screening
symptoms and chest X-ray screen. There were eight survey cases who had screening
symptoms but whose chest X-rays were interpreted as not suggestive of TB by the
both the field team leader and off-site radiologist.

Table 40. Distribution of smear-positive and bacteriologically confirmed TB cases

according to symptoms screening and chest X-ray results (field
reading), 2016 NTPS, Philippines (N=466)

Field chest Smear-positive MTB Bacteriologically confirmed

Screening
X-ray (N= 173) TB cases (N=466)
symptoms
reading No. %a No, %a
Positive Positive 79 45.7 132 28.3
Positive Negative 3 1.7 8 1.7
Positive Exempted 6 3.5 10 2.1
Negativeb Positive 80 46.2 298 63.9
Negativeb Exempted 5 2.9 18 3.9
Total 173 100.0 466 100.0
a
Column percentage
b Negative—includes those with other symptoms of fever, weight loss, night sweats and cough of any duration

The sensitivity of screening symptoms (≥2 weeks and/or hemoptysis) in identifying

survey TB cases was 32.2% (95% CI: 28.0─36.6%) while the specificity was 94.2%
(CI: 94.0─94.4%) (Table 43). For screening using cough of any duration with or without
hemoptysis, the sensitivity increased to 58.8% (95% CI: 54.2─63.3%) but the
specificity decreased to 77.0% (95% CI: 77.0─77.4%).

Table 41. Sensitivity and specificity of screening symptoms using the final
survey case classification as the gold standard, 2016 NTPS,
Philippines (N=46,689)

Final diagnosis
Screening symptomsa Total
Survey cases Not TB
Positive 150 2,665 2,815
Negative 316 43,558 43,874
Total 466 46,223 46,689
aScreening symptoms cough 2 weeks and/or hemoptysis
Sensitivity: 32.2% (95% CI: 28.0%–36.6%)
Specificity: 94.2% (95% CI: 94.0%–94.4%)
Positive predictive value: 5.3% (95% CI: 4.5%–6.2%)
Negative predictive value: 99.3% (95% CI: 99.2%–99.4%)

78
On the other hand, the sensitivity of the chest X-ray field reading (suspicious for TB
as read by the field team leader and/or off-site radiologist) was 98.2% (95% CI:
96.4─99.2%) while the specificity was 71.4% (95% CI: 71.0─71.9%) (Table 44).

Table 42. Sensitivity and specificity of field reading of chest X-rays using the
final survey case classification as the gold standard, 2016 NTPS,
Philippines (N=46,689)

Final diagnosis
Chest X-ray field readinga Total
Survey cases Not TB
Positive 430 11,716 12,146
Negative 8 29,289 29,297
Total 438 41,005 41,443
aChest X-ray field reading: positive means suspicious for TB as read by the field team leader and/or off-site
radiologist
Sensitivity: 98.2% (95% CI: 96.4%–99.2%)
Specificity: 71.4% (95% CI: 71.0%–71.9%)
Positive predictive value: 3.5% (95% CI: 3.2%–3.9%)
Negative predictive value: 100.0% (95% CI: 99.9%–100.0%)

Based on the final interpretation of the central radiologist, 409 (87.8%) of the 466
survey TB cases had chest X-rays suggestive of TB. Of the 409 with X-rays suggestive
of TB, 168 (41.1%) were negative for screening symptoms but had other non-specific
symptoms, while 108 (26.4%) were asymptomatic. For 5 survey cases who did not
have screening symptoms, and 17 others who did not have screening symptoms but
reported other non-specific symptoms, their chest X-rays were read by the central
radiologists as not suggestive of TB. Only six survey cases with screening symptoms
had normal chest X-rays based on readings of the central radiologists (Table 45).

Among the 466 survey cases, only 437 (93.8%) had chest X-rays done (Table 46).
One X-ray, which was considered of poor quality, was from a participant with screening
symptoms. Of the 28 BCTB participants without a chest X-ray, 10 were positive for
screening symptoms; 10 had no screening symptoms but had other non-specific
symptoms; and 8 were asymptomatic. Reasons for not having a chest X-ray included
pregnancy in 2 participants, on-site refusal due to recent chest X-ray in 4 participants,
while 22 who were interviewed house-to-house refused to go to the site to have an X-
ray done.

79
 Table 43. Distribution of symptoms and chest X-ray results (central reading) of
survey cases, 2016 NTPS, Philippines

Smear-positive Bacteriologically
Chest X-ray survey cases confirmed survey cases
Screening
(Central (N=173) (N=466)
symptoms
reading)
No. %a No. %a
Positive Positive 79 45.7 133 28.5
Positive Negative 2 1.2 6 1.3
Negative but with Positive 56 32.4 168 36.0
other symptomsb
Negative but with Negative 2 1.2 17 3.6
other symptomsb
Negative Positive 21 12.1 108 23.2
Negative Negative 1 0.6 5 1.1
Positive Poor image 1 0.6 1 0.6
Positive CXR N/Dc 6 4.0 10 2.4
Negative but with CXR N/D 2 1.2 10 2.1
other symptomsb
Negative CXR N/D 3 1.7 8 1.7
Total 173 100.0 466 100.0
a Column percentage
b Other symptoms: fever, weight loss, night sweats
c N/D: not done

Of the 437 available chest X-rays, 409 (93.6%) were interpreted as suggestive of TB.
Only 10 X-rays were read as normal and another 15 were interpreted as pulmonary
abnormality not suggestive of TB—mostly pneumonic infiltrates in the lower lung fields
(Table 46).

Majority of the lesions suggestive of TB were unilateral and bilateral fibrohazy or

reticular infiltrates (255 out of 409, or 62.3%), while another 141 (34.5%) were mixed
fibrohazy or reticular infiltrates with nodules, cavities and calcifications. There were 72
(17.6%) with cavities, with or without other lesions.

The chest X-ray lesions were quite extensive, with 275 of the lesions located bilaterally
(67.2%), mostly in the apices and mid lung fields. Unilateral lesions were also
commonly found in the right apex (73, or 17.8%) and left apex (39, or 9.5%). Other
lesions seen were bullae formation, endobronchial spread, bronchiectasis,
cicatrization, and tracheal deviation.

80
 Table 44. Chest X-ray results of the survey TB cases, 2016 NTPS, Philippines
(N=466)

Chest x-ray readings by the central radiologists No. %

With chest X-ray reading 437 93.8
Chest X-ray not done (includes one poor quality chest X-ray image) 29 6.2
Overall interpretation (n=437)
Pulmonary abnormality suggestive of TB 409 93.6
Pulmonary abnormality, not TB 15 3.4
Abnormality, not TB 3 0.7
Normal 10 2.3
Types of TB infiltrates or residuals (n=409)
Fibrohazy or reticular (unilateral 98, bilateral 157) 255 62.3
Nodular (unilateral 5, bilateral 1) 6 1.5
Cavity (unilateral 5, bilateral 1) 6 1.5
Calcifications (unilateral) 1 0.2
Fibrohazy or reticular, nodular (unilateral 13, bilateral 50) 63 15.4
Fibrohazy or reticular, cavity (unilateral 10, bilateral 34) 44 10.8
Fibrohazy or reticular, nodular, cavity (bilateral) 16 3.9
Fibrohazy or reticular, calcification (unilateral 2, bilateral 5) 7 1.7
Fibrohazy or reticular, nodular, calcification (bilateral) 5 1.2
Fibrohazy or reticular, nodular, cavity, calcification (bilateral) 5 1.2
Fibrohazy or reticular, cavity, calcification (unilateral) 1 0.2
Location of lesions (n=409)
Unilateral 134 32.8
Right apex 73 17.8
Right mid lung field 2 0.5
Right apex and mid lung field 8 2.0
Right mid and lower lung field 3 0.7
Right apex, mid and lower lung field 2 0.5
Left apex 39 9.5
Left mid lung field 3 0.7
Left apex and mid lung field 3 0.7
Left mid and lower lung field 1 0.2
Bilateral 275 67.2
Apices 157 38.4
Apices and midlung fields 74 18.1
Apices, mid and lower lung fields 35 8.6
Mid lung fields 5 1.2
Apices and lower lung fields 3 0.7
Mid and lower lung fields 1 0.2

5.3.3. Screening symptoms eligibility and current TB treatment among survey

cases

Among the 30 survey cases who were currently on treatment, 12 still reported the
presence of screening symptom at the time of the survey. All 12 were Xpert-positive,
two of whom were retreatment cases whose cultures were still positive and with
rifampicin resistance detected on Xpert MTB/RIF. One of the latter was resistant to
isoniazid, rifampicin, streptomycin, ethambutol, and levofloxacin on drug susceptibility

81
 testing. The other 18 were positive on Xpert MTB/RIF only and were symptom screen-
negative (Table 47).

Among those with no history of treatment, the majority stated that they did not have
any of the screening symptoms (54.7%). Likewise, among those with a previous
history of treatment, there were more symptom screen-negative individuals (9.2%)
compared to those with screening symptoms.

Table 45. Distribution of bacteriologically confirmed PTB survey cases according to

presence of screening symptoms and history of TB treatment, 2016 NTPS,
Philippine (n=466)

Xpert-positive
MTB culture-
Xpert- positive and MTB
Screening History of TB positive Total
only culture-
symptoms treatment only
positive
No. %a No. %a No. %a No. %a
With previous
treatment 18 3.9 2 0.4 14 3.0 34 7.3
Currently on
treatment 9 1.9 0 0.0 0 0.0 9 1.9
Positive With current
and
previous
treatment 1 0.2 0 0.0 2 0.4 3 0.6
None 33 7.1 15 3.2 56 12.0 104 22.3
With previous
treatment 25 5.4 7 1.5 11 2.4 43 9.2
Currently on
treatment 17 3.7 0 0.0 0 0.0 17 3.6
Negative With current
and
previous
treatment 1 0.2 0 0.0 0 0.0 1 0.2
None 134 28.8 45 65.0 76 16.3 255 54.7
Total 238 51.1 69 14.8 159 34.1 466 100.0
a Computed over total number of bacteriologically confirmed TB cases (n=466)

5.3.4. History of treatment of survey TB cases

Of the 466 survey TB cases, 359 (77%) were new cases, while 77 (16%) had a history
of previous treatment for TB, and 30 (6%) said they were currently on treatment at the
time of the survey (Table 48). Of the 30 who were currently on treatment, 14 were on
the intensive phase and 17 were on the maintenance phase of treatment at the time

82
of the survey. Four of the 30 cases currently on treatment also reported having been
treated for TB in the past.

Of the new cases and those currently on treatment without a history of TB treatment,
12 (3.1%) were found to be rifampicin-resistant by Xpert MTB/RIF. On the other hand,
among the 81 with previous TB treatment survey, 17 (21%) were rifampicin-resistant
by Xpert MTB/RIF. Having had previous TB treatment was significantly associated
with rifampicin resistance by Xpert (P<0.0001), with an odds ratio of 8.2 (95% CI: 3.8–
18.0) (Table 48). It was also noted that 12 of the 17 with past treatment (70.6%) had
been treated in the last six years, while 5 (29.4%) had been treated on or before 2010.
However, poorer recall of more distant events could have been a source of recall bias.

Table 46. Association of TB treatment history with rifampicin resistance on

Xpert MTB/RIF among survey TB cases, 2016 NTPS, Philippines
(N=466)

Xpert RIF resistance Xpert RIF resistance

Previous TB
detected not detected Total
treatment
No. (%) No. (%)
Yes 17 (21.0) 64 (79.0) 81
No 12 (3.1) 373 (96.9) 385
Total 29 (6.2) 437 . 466
O.R. = 8.2 (95% CI: 3.8−18)

With respect to the 30 survey TB cases who reported that they were currently on
treatment at the time of the survey, 21 (70%) were smear- and culture-negative but
still Xpert-positive, while 9 (30%) were still smear-positive (2 culture-positive and
Xpert- positive; 7 culture-negative and Xpert-positive) (Table 49). Both of the
participants who were still culture- and Xpert-positive were RIF-resistant, one of whom
was in the intensive phase of treatment with first-line drugs while the other was already
on the maintenance phase of treatment with isoniazid and rifampicin. Of the 7 smear-
positive, culture-negative and Xpert-positive participants, 3 were still in the intensive
phase, while 4 were in the maintenance phase already. Excluding the 21 cases who
were smear-negative and currently on treatment from the 466 survey cases, 136
(29.2%) cases were missed by smear or were truly smear-negative.

83
 Table 47. Survey case classification by treatment history, 2016 NTPS,
Philippines (N=466)

With
Survey Currently on
previous TB New cases
TB cases cases treatment
treatment
No. %a No. %a No. %a No. %a
Smear-positive
TB culture-positive and
109 23.4 17 22.1 2 6.7 90 25.1
Xpert-positive
TB culture-positive and
19 4.1 6 7.8 0 0.0 13 3.6
Xpert-negative
TB culture-negative and
45 9.7 10 13.0 7 23.3 28 7.8
Xpert-positive
Smear-negative
TB culture-positive and
50 10.7 8 10.4 0 0.0 42 11.7
Xpert-positive
TB culture-positive and
50 10.7 3 3.9 0 0.0 47 13.1
Xpert-negative
TB culture-negative and
189 40.6 32 41.6 21 70.0 136 37.9
Xpert-positive
Smear and TB culture
(not done) and Xpert- 4 0.9 0 0.0 0 0.0 3 0.8
positive
Total 466 100.0 77 100.0 30 100.0 359 77.0
a Column percentage

5.3.5. General characteristics of the bacteriologically confirmed PTB survey

cases

The highest number of cases was in the age group 45−54 years (22.1%), while the
lowest proportion of cases was in the age group 25–34 years (14.6%). There were
more cases of TB among men (1.5%) than women (0.6%) with a 3:1 ratio (P<0.001).
(Table 50).

Stratum 1, which had twice the required sample size as the other clusters, had the
highest number of PTB cases (40%), followed by stratum 3 (24%) and stratum 4
(20%). Stratum 2 had the least number of cases (16%). The proportion of TB cases
was greater in the urban areas (1.1%) compared to the rural areas (0.9%) (P=0.006).

84
 Table 48. Socio-demographic characteristics of survey TB cases compared
to those without TB, 2016 NTPS, Philippines (N=46,689)

Survey TB Total survey

Not TB
cases participants
Characteristics (n=46,223)
(n=466) (N=46,689)
No. %a No. %a No. %a
Stratum
1 187 40.1 15,861 34.0 16,048 34.4
2 77 16.5 9,271 19.9 9,348 20.0
3 111 23.8 9,592 20.5 9,703 20.8
4 91 19.5 11,499 24.6 11,590 24.8
Age group (years)
15–24 72 15.5 11,866 25.4 11,938 25.6
25–34 68 14.6 9,044 19.4 9,112 19.5
35–44 76 16.3 8,165 17.5 8,241 17.7
44–54 103 22.1 7,059 15.1 7,162 15.3
55–64 73 15.7 5,440 11.7 5,513 11.8
 65 74 15.9 4,649 10.0 4,723 10.1
Sex
Male 322 69.1 20,571 44.1 20,893 44.7
Female 144 30.9 25,652 54.9 25,796 55.3
Urban/rural classification
Urban 244 52.4 21,282 45.6 21,526 46.1
Rural 222 47.6 24,941 53.4 25,163 53.9
Total 466 100.0 46,223 100.0 46,689 100.0
a Column percentage

Of the 106 clusters, only four clusters (3.8%) had no survey cases. The number of
cases per cluster ranged from 1–13, with an average of four cases per cluster. Sixty-
one (57.5%) clusters had 1–4 cases; 28 (26.4%) had 5–8 cases; and 13 (12.3%) had
nine or more cases (Fig. 12).

Figure 12. Distribution of prevalence by cluster (N=106), 2016 NTPS, Philippines

85
Figure 13 shows the age and sex distribution of the survey cases. Across all age
groups, there were more men with TB compared to women. Most of the survey cases
were predominantly among men aged 45–54 years (16.1%), while the lowest
proportion of survey cases was among women aged 55–64 years. Among the 466
survey cases, the percentage of TB cases was higher among men across all age
groups compared to women of the same age groups (P<0.001 to 0.030) (Fig. 12).

18.0
16.1
16.0

14.0
12.4 12.4
12.0
Survey TB cases

9.9
10.0 9.4
8.8
8.0 Male
6.0 5.8 6.0 6.0
6.0 Female
3.9
4.0 3.2

2.0

0.0
15-24 25-34 35-44 45-54 55-64 65 and
above
Age group (years)

Figure 13. Age and sex distribution of the 466 survey cases, 2016 NTPS, Philippines
(N=466)

Twenty six of the 466 survey cases (5.6%) were identified during the house-to-house
visits as part of the mopping-up operations while the rest were identified on-site. There
were significantly fewer survey cases identified among those interviewed at home
(0.6%) than those interviewed on-site (1.0%) (P=0.007)—however, it should be noted
that there were more sputum-eligible participants interviewed off-site who did not
provide sputum samples compared to sputum-eligible participants identified on-site
(38.2% and 6.1%, respectively).

In terms of education, most of the survey participants with TB completed at least high
school (42%) and elementary studies (39%). Majority were employed (53%) and with
health insurance (56%). Among the employed, most were in the service or sales
workforce (23%), followed by agriculture, forestry and fishery workers (11%), laborers
(9.0%), and managers (7%) (Table 51).

86
 Table 49. Socio-demographic characteristics of survey TB cases compared
to those without TB, 2016 NTPS, Philippines (N=46,689)

Total
Survey cases Not TB
participants
Characteristics (n=466) (n=46,223)
(N=46,689)
No. %a No. %a No. %a
Highest educational attainment
No schooling 11 2.4 844 1.8 855 1.8
Pre-elementary/elementary 183 39.3 14,995 32.2 15,178 32.6
High School 195 41.8 18,109 38.8 18,304 39.2
Vocational 19 4.1 2,432 5.2 2,451 5.2
College/postgraduate 58 12.4 9,843 21.1 9,901 21.2
Civil status
Single 110 23.6 12,941 27.7 13,051 28.0
Married 216 46.4 22,049 47.2 22,265 47.7
Currently living-in 87 18.7 7,014 15.0 7,101 15.2
Widowed/divorced/separated 53 11.3 4,219 9.0 4,272 9.2
With health insurance
Yes 262 56.2 29,713 63.6 29,975 64.2
No 197 42.3 15,997 34.3 16,194 34.7
No information/don’t know 7 1.5 513 1.1 520 1.1
Don’t know 4 0.9 169 0.4 173 0.4
Work Status
Employed 248 53.2 21,618 47.1 21,866 46.8
Unemployed 124 26.7 8,670 18.8 8,741 18.7
Housewife 64 13.7 10,551 22.8 10,615 22.7
Student 30 6.4 5,437 11.6 5,467 11.7
Occupation
Without formal employment 124 26.6 8,695 18.8 8,819 18.9
Sales/ Service 106 22.7 8,517 18.4 8,623 18.5
Agriculture/forestry/fishery 50 10.7 3,782 8.2 3,832 8.2
Laborer 42 9.0 2,898 6.3 2,940 6.3
Managers 33 7.1 3,971 8.6 4,004 8.6
Professionals/associates 6 1.3 1,353 2.9 1,359 2.9
Trades 5 1.1 352 0.8 357 0.8
Clerks 2 0.4 362 0.8 364 0.8
Plant/machine operator 2 0.4 172 0.4 174 0.4
Others 2 0.4 133 0.3 135 0.3
Housewife 64 13.7 10,551 22.8 10,615 22.7
Student 30 6.4 5,437 11.8 5,467 11.7
Total 466 100.0 46,223 100.0 46,689 100.0
a Column percentage

The proportion of cases of TB among those who reported they had diabetes mellitus
was higher (8%) compared to non-cases (4%) (P<0.001). There were also more cases
of TB among those with history of smoking (67%) compared to non-cases (39%)
(P<0.001) (Table 52).

87
 Table 50. Risk factors for survey cases compared to non-cases, 2016 NTPS,
Philippines (N=46,689)

Total
Survey cases Non-cases
participants
Characteristics n=466 n=46,223
N=46,689
No. %a No. %a No. %a
Diabetes mellitus
Yes 38 8.2 1,828 4.0 1,866 4.0
No 428 91.8 44,395 96.0 44,823 96.0
Smoking
Yes 313 67.2 18,222 39.4 18,535 39.7
No 153 32.8 27,975 60.5 28,128 60.2
Don’t know 0 0.0 26 0.1 26 0.1
Total 466 100.0 46,223 100.0 46,689 100.0
a Column percentage

5.3.6. Comparison of households with and without TB cases

The 466 survey cases came from 456 households, among which 10 households had
two TB cases each. Strata 1, 2, and 3 had three households each with two TB cases,
while stratum 4 had one household with two TB cases. Two cases of multi-drug
resistant TB were identified in one household in Strata 1.

Table 53 is a comparison of the socio-demographic characteristics of households with

and without TB cases. Among households with TB cases, stratum 1 had the highest
proportion of households with TB cases, followed by stratum 3, stratum 4, and stratum
2. The proportion of households with TB cases located in urban areas (2.8%) was also
higher than those in rural areas (2.1%) (P=0.006).

The percentage of households with TB cases was higher as the household size
increased to ≥5 members compared to households without TB cases (P=0.001).

Only a small percentage of households were enrolled in the 4Ps conditional cash
transfer program, but the proportion of households with TB cases enrolled in the 4Ps
program was higher than households without TB cases (P=0.004). Using enrolment in
the 4Ps conditional cash transfer program and ownership of a refrigerator or freezer
in the house as proxies for socio-economic status, the proportions of households with
TB cases who were beneficiaries of the 4Ps program or who did not have a refrigerator
were higher compared to households without TB cases (P=0.004 for 4Ps membership,
P<0.001 for absence of a refrigerator). This suggested that more households with TB
cases belonged to the lower socio-economic bracket.

88
 Table 51. Socio-demographic characteristics of households with and without
TB cases, 2016 NTPS, Philippines (N=18,830)

Households with Households Total

TB cases without TB households
Characteristics (n=456) cases (n=18,374) (N=18,830)
No. %a No. %a No.
Stratum
1 184 40.4 6,437 35.0 6,621
2 74 16.2 3,775 20.5 3,849
3 108 23.7 3,643 19.8 3,751
4 90 19.7 4,519 24.6 4,609
Household size
1−4 207 45.4 9,826 53.5 10,033
5−8 212 46.5 7,661 41.7 7,873
>8 37 8.1 887 4.8 924
Urban/rural classification
Urban 238 52.2 8,404 45.7 8,642
Rural 218 47.8 9,970 54.3 10,188
4Ps beneficiary
Yes 122 26.8 3,883 21.1 4,005
No 332 72.8 14,402 78.4 14,734
No data 2 0.4 89 0.5 91
Refrigerator/ freezer in the
house
Yes 109 23.9 6,975 38.0 7,084
No 345 75.7 11,321 61.6 11,666
No data 2 0.4 67 0.4 69
Don’t know 0 0.0 11 0.1 11
Smoker in the household
Yes 393 86.2 12,342 67.2 12,735
No 63 13.8 6,032 32.8 6,095
Total 466 100.0 46,223 100.0 18,830
a Column percentage

5.3.7. Health seeking behavior of survey participants and survey TB cases who
reported being currently treated for TB

A total of 170 out of the 46,689 (0.4%) participants interviewed reported that they were
currently being treated for TB at the time of the survey. Among these, 130 (76.5%)
received treatment from the local health center or the TB DOTS clinic and 123 (72.3%)
sourced their anti-TB medicines from these public facilities. The rest of the participants
either received treatment or sourced their medications from the private sector, mostly
from a private pharmacy (n=30, or 18.3%), followed by private clinics and hospitals
(Table 54). Of the 170 survey participants, only 84 (49.4%) could be traced in the

89
Integrated TB Information System of the NTP. Of those who could be traced in the TB
registry, 94% were reported by public providers.

Table 52. Health-seeking behavior of survey participants cases who

reported being on TB treatment at the time of the survey,
2016 NTPS, Philippines (N=170)

Total participants
Characteristics currently on treatment
No. %a
Health facility where treatment was received
Provincial hospital/ public medical center 3 1.8
Local health center/ DOTS TB Clinic 130 76.5
Other public facility 1 0.6
Private hospital 5 2.9
Private clinic 8 4.7
Private pharmacy 21 12.3
Given by relatives 1 0.6
No data 1 0.6
Source of anti-TB medicines
Provincial hospital/ public medical center 2 1.2
Local health center/ DOTS TB Clinic 123 72.3
Other public 1 0.6
Private hospital 2 1.2
Private clinic 5 2.9
Private pharmacy 30 18.3
Given by relatives/ friends 1 0.6
No data 3 1.8
a Column percentage

In terms of diagnostic tests done, the majority of the 170 who were currently on
treatment (68%) had both chest X-ray and sputum examination done, while 30% had
only one of the two tests. Among participants who were being treated by a public
provider, majority (75.9%) had both chest X-ray and sputum AFB smear done.
However, among those who were being treated by a private provider, majority (52.8%)
had a chest X-ray only, while only 38.9% participants had both chest X-ray and sputum
AFB smear done. Only 2 participants neither had a chest X-ray nor sputum
examination done prior to treatment. Eight of the participants were instructed to either
have an X-ray or sputum examination done but were unable to comply. Reasons
included cost of X-ray, inability to produce sputum, and long turnaround time for the
test result.

90
Thirty (6.4%) of the 170 participants currently on anti-TB treatment were still
bacteriologically confirmed cases (6.4%) (Fig. 14).

30
436 6.4% 140

Participants currently
Survey TB cases under anti-TB treatment
Figure 14. Distribution of survey participants and survey TB cases
who were currently under TB treatment

Of the 30 survey cases who were receiving TB medications at the time of the survey,
24 were receiving TB drugs from DOTS clinics, while 6 patients were being treated in
the private sector.

Five of the 30 participants reported stopping their medications at some point during
treatment. Four of these 5 were in the NTP registry (3 under DOTS and 1 under
PMDT). The reasons for default were the following: side effects (2); cost of drugs (1);
far distance of health center (1); patient too weak to go to the health center (1); and
stock-out of drugs (1).

Four of the 5 defaulters among those who reported to have been on “current treatment”
were still smear-positive and bacteriologically confirmed, and 3 were rifampicin-
resistant on Xpert MTB/RIF at the time of the survey, including the participant currently
undergoing treatment under PMDT. These 4 patients were already in the maintenance
phase at the time of the survey.

91
5.4. TB prevalence estimates

The estimated prevalence of bacteriologically confirmed PTB in those ≥15 years was
1,159 per 100,000 (95% CI: 1,016–1,301), and the estimated prevalence of smear
positive, bacteriologically confirmed TB was 434 per 100,000 (95% CI: 350─518) (Fig.
15). Both the prevalence for smear-positive and bacteriologically confirmed TB were
higher in men compared to women with a male-to-female ratio of 2.5:1 (Table 51).
Prevalence increased with age and was highest among the 45─54-year age group
(smear-positive prevalence of 665 per 100,000; bacteriologically confirmed TB
prevalence of 1,714 per 100,000), followed by the age groups ≥65, 55─64, and 35─44
years. For the youngest age group in the survey (15─19 years), the estimated
prevalence for bacteriologically confirmed TB was 613 per 100,000 (95% CI:
403─822), and that for smear positive, bacteriologically confirmed TB was 151 per
100,000 (95% CI: 48─254). Stratum 1 had the highest prevalence of smear-positive
and bacteriologically confirmed TB, followed by stratum 3, stratum 4 and stratum 2,
but with some degree of overlap in the 95% confidence intervals. (Table 55)

Table 53. Estimated prevalence of smear positive and bacteriologically

confirmed PTB among individuals aged ≥15 years, age group and
stratum, 2016 NTPS, Philippines (N=46,689)

Smear-positive PTB Bacteriologically confirmed PTB

(N=173) (N=466)
Prevalence Prevalence
No. 95% CI No. 95% CI
estimatea estimatea
National 173 434 350–518 466 1,159 1,016–1,301
Stratum
1 81 599 451–747 187 1,358 1,103–1,612
2 19 258 138–378 77 1,038 787–1,288
3 44 471 261–680 111 1,234 873–1,594
4 29 268 173–364 91 856 686–1,026
Sex
Male 125 673 528–819 322 1,713 1,482–1,943
Female 48 205 141–270 144 627 516–739
Age group
15─24b 30 330 197–463 72 799 586–1,011
25─34 24 326 195–458 68 900 677–1,123
35─44 32 470 298–641 76 1,126 821–1,430
45─54 40 665 438–891 103 1,714 1,364–2,064
55─64 24 488 285–691 73 1,504 1,104–1,903
65+ 23 503 310–696 74 1,659 1,261–2,058
a
per 100,000; Computed using method 3 (multiple imputation and inverse probability weighting)
b For the age group 15─19 years, the prevalence estimate for smear-positive PTB was 151 per 100,000 (95%
CI: 48─254) while the prevalence estimate for bacteriologically confirmed PTB was 613 (95% CI: 403─822).

92
 Figure 15. Prevalence of smear positive and bacteriologically confirmed TB cases
by age groups, 2016 NTPS, Philippines

Figure 16 shows the prevalence of bacteriologically confirmed TB by diagnostic

method. The estimated prevalence of Xpert-positive TB was 983 per 100,000 (95%
CI: 856–1,110), while the estimated prevalence of culture-positive TB was 587 per
100,000 (95% CI: 488─687).

Figure 16. Prevalence of Xpert-positive and culture-positive TB by age

groups, 2016 NTPS, Philippines

93
5.5. Comparison of 2007 and 2016 NTPS

There are some fundamental differences between the 2007 and 2016 NTPS that
should be considered before making inferences about TB trends during this time
period. These differences pertain to the sampling design, age groups covered,
screening procedures, chest X-ray imaging and interpretation, diagnostic tests used,
and TB case definition. Table 56 outlines the key methodological differences between
the two surveys.

Figures 17–20 compare the geographic distribution of the clusters for the 2007 and
2016 NTPS, illustrating the wider reach of the clusters in the 2016 survey.

The population parameters in the 2007 and 2016 prevalence surveys were also
different (Table 57), particularly the increase in the average population size of the
barangays involved in the two surveys.

Table 54. Differences in the survey methods of the 2007 and 2016 prevalence
surveys, Philippines

Methodologic 2007 NTPSa 2016 NTPS

feature
Sampling design Sampling frame restricted
Sample size requirement of
30,000 for all ages from 50
clusters
Stratified cluster sampling of 50
clusters, but clusters selected
from a pool of 73 in 3 strata
23 excluded: 13 for security
reasons; 5 inaccessible; 5
oversampling
Stratification by urban – rural
classification
Sample of Aged ≥10 years
participants
No. of participants: 22,867
Participation rate: >90%
Screening No symptom screening (but
aged ≥20 years interviewed)
Conventional chest X-ray
Nationwide sampling
Sample size requirement of
51,000 aged ≥15 years from
108 clusters
Stratified cluster sampling of
108 clusters
2 excluded: 1 for security
reasons; 1 poor
participation (urban gated
community)
Stratification into 4 geographic
groupings
Aged ≥15 years and resident of
cluster for ≥2 weeks
No. of participants: 46,689
Participation rate: 76%
Symptom screening: cough ≥2
weeks and/or hemoptysis
Digital chest X-ray

94
 Methodologic 2007 NTPSa
feature
Diagnostic tests 1 main laboratory for all sputum
samples, with some support
from other laboratories
3 sputum samples that were
pooled before processing
1 AFB smear (fluorescence
microscopy with mercury
lamp)
1 AFB culture (hybrid method:
Ogawa/Lowenstein-Jensen
concentration method;
contamination rate: 11%)
Sputum smear 1x smear
microscopy Fluorescent microscopy with
mercury lamp
Culture Different culture methods used:
Concentrated Lowenstein-
Jensen (LJ) method (N=37)
Mixed methods (N=51)
Ogawa and pooled LJ method
(N=5,085—S1, S2, S3)
Contamination rate: 11%
Other diagnostic test N/A
Case definition Bacteriologically confirmed TB:
sputum smear- and/or
culture-positive TB
Smear-positive TB: 2 sputum
smear-positive specimens, or
one smear-positive specimen
associated with a positive
culture MTB or chest X-ray
reading
Culture-positive TB: at least one
sputum specimen culture-
positive TB
a Sources: Tropical Disease Foundation 2008; Tupasi et al. 2009.
2016 NTPS
6 laboratories across the
Philippines
1─3 sputum samples
1 AFB smear (fluorescence
microscopy with LED lamp)
1 Xpert MTB/RIF
1 AFB culture (Ogawa media,
2 tubes; contamination rate:
2─6%)
1x smear
Fluorescent microscopy with
LED lamp
1x Ogawa culture (usually
morning specimen—S2)
Contamination rate: 2–6%
1 Xpert MTB/RIF (S1)
Bacteriologically confirmed TB:
at least one positive result by
sputum Xpert MTB/RIF
and/or culture MTB
Smear-positive TB:
bacteriologically confirmed
TB with a smear-positive
specimen
95
Figure 17. Stratum 1: Location of the clusters in the National Capital Region, Region 3, and Region 4A for the 2007 and 2016 surveys
(inset shows the National Capital Region in greater detail)

96
Figure 18. Stratum 2: Location of the clusters in the rest of Luzon for the 2007 and 2016 surveys (inset shows the cluster in
Palawan)

97
Figure 19. Stratum 3: Location of the clusters in Visayas for the 2007 and 2016 surveys (inset
shows the cluster in Palawan)

98
Figure 20. Stratum 4: Location of the clusters in Mindanao for the 2007 and 2016 surveys
(inset shows the cluster in Tawi-tawi)

99
 Table 55. Population in the clusters of 2007 and 2016 NTPS according to the
2007 and 2015 censusa

2007 NTPS 2016 NTPS

Demographic characteristics
clusters clusters
Total population in survey areas (2007 Census) 375,581 1,423,529
Total population in survey areas (2015 Census) 405,828 1,580,440
Change in survey population from 2007 to 2015 30,247 156,911
Average population per barangay at the time of
7,512 14,770
census
a Adapted from the 2007 & 2015 Census of Population and Housing Reports

In spite of these basic differences in the design of the two surveys, a limited
comparison of the two surveys can be done by restricting the data to the following
common parameters:

 Eligibility to participate criteria:

o 2007 survey: ≥15 years (N=19,341)

o 2016 survey: ≥15 years and residency status (N=61,467)

 Participation defined by:

o 2007 survey: had a chest X-ray (N=17,226)

o 2016 survey: had an interview +/- a chest X-ray (N=46,689)

 Screening outcomes defined by chest X-ray only; screening symptoms in the 2016
survey excluded

 PTB cases defined by Ogawa culture result only (second sample only in 2007
survey); LJ culture results in the 2007 survey excluded; Xpert MTB/RIF results in
the 2016 survey excluded

The restricted analysis yielded smaller but fairly comparable sets of data for the two
survey years in terms of bacteriologically confirmed TB cases and smear-
positive/culture-positive TB cases (Table 58).

100
 Table 56. Distribution of TB cases in the 2007 and 2016 NTPS using restricted
parameters for comparability

2007 NTPS 2016 NTPS

No. of cases No. of cases
No. of cases No. of cases
as per as per
Category as per as per
amended amended
protocola protocol
analysis analysis
Bacteriologically
136 81 466 212
confirmed TB
Culture-
0 81 (72b) 228 212
positive MTB
Smear-
50 36 (33b) 173 118
positive MTBc
a Source: Tropical Disease Foundation, Inc. and Department of Health (2008). Nationwide Tuberculosis
Prevalence Survey 2007. Navotas City, Philippines: Regan Printers, Inc.
b Note: Some ID numbers from the 2007 laboratory database could not completely merge/match with the main

database. Some cases were also excluded because the participant was not eligible to submit sputum based on
chest X-ray screening (i.e., submitted sputum specimens but not eligible to do so).
c Smear-positive TB cases only includes those with a positive TB culture (i.e., 5 probable cases were excluded).

Based on the cases as identified in Table 58, the estimated adjusted prevalence rates
in the adult population for the two years surveyed were:

2007 NTPS 2016 NTPS

Culture-positive TB cases 463 per 100,000 512 per 100,000
(95% range: 333–592) (95% range: 420–603)
Smear-positive with culture- 193 per 100,000 286 per 100,000
positive TB (95% range: 117–269) (95% range: 223–349)

Figure 21 illustrates the trends in PTB prevalence based on the 2007 and 2016
surveys.

Figure 22 shows the density plots for estimating the PTB prevalence for these two
surveys, using 20 simulation cycles. Bearing in mind the caveats listed above on the
basic differences between the two national surveys, the substantial overlap in the 95%
ranges (bands of uncertainty for these estimates) nevertheless suggests no evidence
of a significant decline in the prevalence of culture-confirmed PTB and smear-positive,
culture-confirmed PTB between these two time points. The sample size in 2016 was
not determined to detect a specified effect size in comparison with the 2007 survey,
but used the WHO-recommended approach to reach a specified precision of the best
estimate. The 2016 survey was therefore not powered to detect small differences with
the 2007 survey, but this limitation did not prevent assessing trends. A posterior

101
probability of approximately 75% was estimated that prevalence did not decline over
the period.

Note: The blue lines indicate trends in the point estimates of prevalence. The pink bands
refer to the 95% confidence intervals around the point estimates.

Figure 21. Trends in the 2007 and 2016 NTPS in terms of culture-positive TB
prevalence and smear-positive TB prevalence, Philippines

Note: The black lines indicate trends in the point estimates of prevalence. The pink bands
refer to the 95% confidence intervals around the point estimates.

Figure 22. Distribution of the estimates prevalence rates for culture-positive TB

based on the 2007 and 2016 NTPS, Philippines

102
In the absence of the original databases from the first two national prevalence surveys
carried out in 1981–1983 and 1997, it is difficult to make further extrapolations to
compare the prevalence rates against the 2016 estimates. Nevertheless, it can be
pointed out that a previous comparison of the TB prevalence estimates from the 1997
and 2007 NTPS showed a slight overlap in the 95% confidence intervals for the point
estimates. For smear-positive and/or culture-positive PTB, the prevalence rates were:
960 per 100,000 population (95% CI: 750–1,160) in 1997, compared to 660 per
100,000 (95% CI: 510–810) in 2007 [Tupasi et al. 2009].

5.6. Health care-seeking behavior

5.6.1. Health care-seeking behavior among participants with self-reported

screening symptoms of TB

A total of 2,815 (6%) survey participants reported the presence of the screening
symptoms suggestive of TB (Table 58). Overall, only 19% of these individuals
consulted a healthcare worker, with more females (23.3%) seeking consultation
compared to males (15.9%) (P<0.0001). In terms of age groups, the proportion of
participants ≥65 years seeking consultation was significantly higher (P<0.001). On the
other hand, in both urban and rural areas, the proportion seeking consultation was
about the same (17.7% and 20%, respectively). Of those who consulted a healthcare
worker, a higher proportion consulted public facilities (67%) compared to private
providers (30%), while only 0.4% went to traditional healers (Fig. 23).

A total of 2,273 (80.7%) participants who reported TB screening symptoms either self-
medicated or did not take action. (Table 59)

Forty percent of symptomatic individuals self-medicated, with a higher proportion self-

medicating among females (43.2%) compared to males (38.0%) (P=0.005). In
contrast, a higher proportion of males (45.9%) did not take action compared to females
(33%) (P<0.0001). The proportion of individuals who self-medicated was similar
across all age groups. On the other hand, there was a progressive decrease in the
proportions who did not take action, with the lowest proportion found among
individuals aged ≥65 years (33.7%) (P<0.0001).

103
 3,000 2,815

2,500

2,000
Participants

1,500
1,143 1,130

1,000

534
500

10 18
0
Total participants No action taken Self- medicated Healthcare Traditional healer No data
worker consulted consulted
Action taken

Note: 20 participants answered more than once

Figure 23. Health care-seeking patterns of survey participants with screening symptoms,
2016 NTPS, Philippines

Self-medication was reported more frequently by participants from urban clusters

(44.6%) compared to those from rural ones (36.5%) (P<0.0001) and by females
(43.2%) more than males (38%) (P=0.005). However, the proportion of participants
who did not take action was higher in rural areas (43.2%) than in urban areas (37.5%)
(P=0.002).

Only a little above half of survey participants had data on refrigerator ownership, which
was used as a proxy indicator for socioeconomic status. Among the participants who
did not own a refrigerator, a lower but not statistically significant proportion (17.9%)
consulted a health care worker (P=0.04) compared to those who owned one; a
significantly higher proportion (42.8%) did not take action (P=0.001). Similarly, a
higher proportion (44.8%) did not take action among participants who were 4Ps
beneficiaries compared to those who were not beneficiaries (39.1%) (P=0.006) (Table
59).

The reasons for self-medicating or not taking action were mainly related to behavior
and access (Table 60). The most common reason for self-medicating or not taking
action was the impression that their symptoms were too trivial to warrant consultation

104
(41.2%). The cost of treatment, including travel to the healthcare facility or days of
work lost, was the second most frequently given reason for self-medicating or not
taking action (35.2%). There were significantly more males than females who self-
medicated or did not take action because of a concern about missing school or work
(9.9% vs 3.5%, respectively; P<0.001). In addition, in terms of age, there were
significantly more survey participants in the younger age groups, 15─24 years (11.7%)
and 25─34 years (11.8%), who cited missing school or work as their reasons for self-
medicating or not taking action (P=0.001).

In terms of urban─rural differences, the perceived triviality of symptoms was a reason

given more frequently by participants residing in urban areas compared to rural
clusters (47.3% and 36.0%, respectively,7 P<0.001). A higher proportion of
participants from rural clusters cited cost compared to those from urban clusters
(40.8% and 28.6%, respectively,8 P<0.001) and distance (8.1% and 1.3%,
respectively,9 P<0.001). Moreover, the highest proportions of participants who cited
cost (45.3%) and distance (10%) as reasons for self-medicating or not taking action
were seen in stratum 4.10

7 Breakdown of data by urban/rural classification is not shown here, but is available on request.
8 Breakdown of data by urban/rural classification is not shown here, but is available on request.
9 Breakdown of data by urban/rural classification is not shown here, but is available on request.
10 Breakdown of data by stratum is not shown here, but is available on request.

105
Table 57. Health care-seeking patterns of survey participants with screening symptoms, 2016 NTPS, Philippines (N=2,815)a

Action Taken
With screening Healthcare Traditional
symptoms No action
Characteristics worker healer Self-medicated No data
taken
consulted consulted
No. No. %b No. %b No. %b No. %b No. %b
Age (years)
15–24 403 48 11.9 2 0.5 166 41.2 185 45.9 5 1.2
25–34 346 48 13.9 1 0.3 142 41.0 155 44.8 1 0.3
35–44 424 63 14.9 1 0.2 168 39.6 191 44.8 4 0.9
45–54 476 93 19.5 1 0.2 188 39.5 190 39.9 5 1.1
55–64 575 118 20.5 3 0.5 234 40.7 223 38.8 2 0.3
≥65 591 164 27.7 2 0.3 232 39.3 199 33.7 1 0.2
Sex
Male 1,653 263 15.9 4 0.2 628 38.0 759 45.9 7 0.4
Female 1,162 271 23.3 6 0.5 502 43.2 384 33.0 11 0.9
Urban/rural classification
Urban 1,272 225 17.7 6 0.5 567 44.6 477 37.5 11 0.9
Rural 1,543 309 20.0 4 0.3 563 36.5 666 43.2 7 0.5
Ownership of refrigerator
With refrigerator 844 179 21.2 4 0.5 359 42.5 304 36.0 5 0.6
Without refrigerator 1,954 350 17.9 6 0.3 761 38.9 837 42.8 13 0.7
Don’t know 4 0 0.0 0 0.0 4 100.0 0 0.0 0 0.0
No data 13 5 38.5 0 0.0 6 46.2 2 15.4 0 0.0
4Ps beneficiary
Yes 797 154 19.3 1 0.1 292 36.6 357 44.8 1 0.1
No 2,003 375 18.7 9 0.4 830 41.4 784 39.1 17 0.8
Don’t know 3 0 0.0 0 0.0 3 100.0 0 0.0 0 0.0
No data 12 5 41.7 0 0.0 5 41.7 2 16.7 0 0.0
Total 2,815 534 19.0 10 0.4 1,130 40.1 1,143 40.6 18 0.6
a
Multiple response accepted; cells shaded gray indicate statistically significant differences P <0.01 or lower
b
Row percentage
Note: Screening symptoms of TB: cough ≥2 weeks and/or hemoptysis.

106
 Table 58. Reasons for self-medicating or not taking action among participants with TB
screening symptoms, by sex, 2016 NTPS, Philippines (N=2,273)a

Male Female Total

Reason for self-medicating or not (N=1,387) (N=886) (N=2,273)
taking actiona
No. %c No. %c No. %c
Behavioralb 697 50.3 450 50.8 1,147 50.5
Symptoms not deemed significant 582 42.0 355 40.1 937 41.2
Uneasy/does not trust health provider 56 4.0 40 4.5 96 4.2
Felt they knew what to do 22 1.6 21 2.4 43 1.9
Used the same prescriptions for a
similar illness in the past 36 2.6 32 3.6 68 3.0
Dislikes seeking medical attention or
taking drugs 11 0.8 9 1.0 20 0.9
Used alternative medicine 3 0.2 6 0.7 9 0.4
Health service deliveryb 19 1.4 17 1.9 36 1.6
Avoid crowds in facilities 14 1.0 7 0.8 21 0.9
Concern about privacy 5 0.4 6 0.7 11 0.5
No doctor in health facility 1 0.1 4 0.5 5 0.2
Accessb 524 37.8 351 39.6 875 38.5
Cost 478 34.5 323 36.5 801 35.2
Distance 69 5.0 44 5.0 113 5.0
No health insurance 1 0.1 1 0.1 2 0.1
Physiologicb 7 0.5 11 1.2 18 0.8
PWD 7 0.5 5 0.6 12 0.5
Pregnant 0 0.0 6 0.7 6 0.3
Othersb 221 15.9 81 9.1 302 13.3
Time constraint 94 6.8 56 6.3 150 6.6
Concern about missing school/workd 138 9.9 31 3.5 169 7.4
No reason 14 1.0 6 0.7 20 0.9
Don’t know 4 0.3 3 0.3 7 0.3
No data 7 0.5 9 1.0 16 0.7
a Multiple response allowed
b Total survey participants with one or more reasons mentioned for each sub-category
c Column percentage
d Statistically significant difference: more males self-medicated or did not take action because of concern about missing school

or work (P<0.001).

Of the 2,280 participants who reported having the screening symptoms of TB and did
not seek formal medical consultation, 1,390 (61.0%) were males. Although there were
more males than females who consulted a non-healthcare worker for their symptoms,
the reasons provided by males and females were not significantly different (Table 61).

The predominant reason for not consulting a health worker was the perception that
their symptoms were not significant (43.9%), and there were no significant differences

107
among the age groups in the proportions providing this reason. The anticipated cost
of consultation prohibited 35.9% of these participants from seeking care from a health
worker. Reasons related to access, specifically cost considerations, were significantly
higher among individuals aged ≥65 years (46.1% vs. 32.6─39.6% in the other age
groups) (P=0.007). Time constraints as a reason for not consulting a healthcare worker
were cited more frequently by the younger age groups 15─24 years and 25─34 years
(13.3% and 13.4%, respectively) compared to the age groups ≥35 years (3.2─12.4%)
(P<0.001). Embarrassment or being afraid to have a formal health consultation was
found more frequently in the younger age group 15─24 years (7.6% vs 1.8─3.7% in the
other age groups) (P<0.001).

In terms of urban─rural differences, perceived triviality of symptoms was given more

frequently as a reason by participants from urban clusters (50.4% vs 38.5% for
participants from rural clusters,11 P<0.001). More participants from rural areas (41.8%)
were concerned with cost compared to those from urban areas (28.9%) (P<0.001).
Distance from the health care facility was cited as a reason more frequently by
participants from rural clusters (7.9% vs. 2% of participants from urban clusters,
P<0.001).

11 Breakdown by urban/rural classification is not shown here, but is available on request.

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 Table 59. Reasons for not seeking formal medical consultation among participants with
TB screening symptoms, by sex, 2016 NTPS, Philippines (N=2,280)

Male Female Total

Reasons for consulting a non- (n=1,390) (n=890) (N=2,280)
healthcare workera
No. %c No. %c No. %c
Behavioralb 697 50.1 429 48.2 1,126 49.4
Symptoms not deemed
significant 631 45.4 371 41.7 1,002 43.9
Embarrassed/afraid 41 2.9 38 4.3 79 3.5
Refused to get checked up 14 1.0 13 1.5 27 1.2
Used the same prescriptions for
a similar illness in the past 12 0.9 10 1.1 22 1.0
Health service deliveryb 5 0.4 8 0.9 13 0.6
No doctor in health facility 3 0.2 7 0.8 10 0.4
No medicine in health facility 2 0.1 1 0.1 3 0.1
Accessb 531 38.2 356 40.0 887 38.9
Cost 486 35.0 332 37.3 818 35.9
Distance 69 5.0 49 5.5 118 5.2
Physiologicb 9 0.6 10 1.1 19 0.8
PWD 9 0.6 5 0.6 14 0.6
Pregnant 0 0.0 5 0.6 5 0.2
Othersb 161 11.6 78 8.8 239 10.5
Time constraint 152 10.9 70 7.9 222 9.7
No reason 9 0.6 8 0.9 17 0.7
No data 15 1.1 17 1.9 32 1.4
a Multipleresponse allowed
b Total survey participants with one or more reasons mentioned for each sub-category
c Column percentage

5.6.2. Health care-seeking behavior among survey TB cases

Of the 466 TB cases identified in the survey, 150 (32.3%) had screening symptoms of
≥2 weeks cough and/or hemoptysis. However, only 44 (29.3%) consulted a healthcare
worker, with 33 (75.0%) consulting a public provider and 10 (22.7%) going to a private
provider. Compared to the other survey participants who were not identified as TB
cases but had screening symptoms, significantly more TB cases consulted a
healthcare provider (19.0% vs 29.3%) [P=0.001].

There were 56 (37.3%) who self-medicated and 51 (34.0%) who did not take any
action at the time they experienced the symptoms. A total of 107 (70.9%) of the

109
symptomatic TB cases did not seek formal health care (Table 62). The main reasons
for self-medicating or not taking action were similar to the other 2,665 survey
participants who were not identified as having TB but had screening symptoms.

Table 60. Distribution of health care-seeking behavior of symptomatic survey TB

cases (n=150) compared to other survey participants who had screening
symptoms (n=2,665), 2016 NTPS, Philippines

Other survey
Health care-seeking behavior Survey TB cases with participants with
of those with screening symptoms symptoms
symptomsa (n=150) (n=2,665)
No. % No. %
b
Consulted a healthcare worker 44 29.3 490 18.4
Public providersc 33 75.0 326 66.5
Private providersc 10 22.7 156 31.8
Othersc 0 0.0 3 0.6
No datac 1 2.3 5 1.0
Self-medicatedb 56 37.3 1,074 40.3
Consulted traditional healerb 0 0.0 10 0.4
Did not take actionb 51 34.0 1,092 41.0
No datab 0 0.0 18 0.7
Total no. of responses 151d. 2,684e
a Multiple response accepted
b Column percentage based on number of individuals
c Percentage calculated over participants who consulted a healthcare worker
d 1 individual answered more than once
e 19 individuals answered more than once

5.6.3. Health care-seeking behavior among participants with history of TB

There were 2,563 survey participants who reported that they had been treated
previously for TB. A total of 1,574 (3.4%) had TB treatment in 2010 or earlier, while
989 (2.1%) were treated in 2011 onwards. To reduce recall bias, additional questions
on the nature of the care they received and their own health actions were only asked
from participants receiving TB treatment from 2011 onwards. In this subset of patients,
there were more male patients (616 out of 20,782, or 3.0%) compared to females (373
out of 25,737, or 1.4%) (P=0.0001) with previous treatment. Most of these patients
had a sputum examination (845 out of 989, or 85.4%) and a chest X-ray (871 out of
989, or 88.1%), but 10.8% (n=91) and 6.8% (n=59) did not know the results of the

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sputum examination or chest X-ray. There were no significant differences between the
male and female patients with respect to any of the aspects of TB care (Table 63).

With respect to age, there were significantly more individuals in the age groups 55─65
years (198 out of 5,482, or 3.6%) and ≥65 years (167 out of 4,693, or 3.6%) who had
previous TB treatment in 2011 onwards (P<0.001) compared to the younger age
groups (range: 0.9%─2.7%, with the age group 15─24 years having the lowest
proportion). In terms of the sputum microscopy results, there were significantly more
individuals in the age groups ≥35 years who said their sputum examination result was
positive (35─44 years: 110 out of 150 (73.3%); 45─54 years: 119 out of 163 (73.0%);
55─64 years: 124 out of 176 (70.5%); ≥65 years: 98 out of 140 (70.0%)) (P=0.001)
compared to those aged 15─24 years and 25─34 years (61.9% and 58.3%,
respectively). There were no other significant differences among the age groups with
respect to TB care.12

Stratum 1 had the highest proportion (7.2%) of participants who ever had TB
treatment, followed by stratum 3 at 5.4%, stratum 2 at 4.7%, and stratum 4 at 3.9%
(P<0.0001). There were more participants coming from the urban than rural areas
(2.5% vs 1.8% of all survey participants, P=0.0001).13

Participants were asked if they had taken or been given specific anti-TB drugs (e.g.
isoniazid, rifampicin, pyrazinamide, ethambutol, or streptomycin). Of the 989
individuals with previous TB treatment from 2011 onwards, 942 (95.2%) said they were
given anti-TB medicines, with 738 (78.3%) getting them from public sector sources,
mainly the health centers and TB DOTS clinics. There were no age or sex differences
in terms of who were given anti-TB drugs. However, there were significantly more
individuals in the rural clusters who received anti-TB drugs compared to those residing
in the urban clusters (82.6% and 74.9%, respectively) (P=0.004). Private sector

12
Breakdown in terms of age groups not shown for other aspects of TB care. Data available on request.
13
Breakdown in terms of stratum and urban/rural classification not shown. Data are available on request.
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sources (i.e. private pharmacies, clinics, hospitals, and NGOs) were the second most
frequently mentioned sources of anti-TB drugs (20.5%), with the proportion being
significantly higher among those residing in urban (24%) than rural areas (16.2%)
(P=0.003).14

There were 162 out of 942 (17.2%) given anti-TB medicines who stopped taking their
anti-TB medicines (Table 64). The most common reasons for stopping medication
were drug-related, mainly side effects (20%) and cost of drugs (17.3%). The most
common reason cited by participants who got their anti-TB medicines from the public
sector and who stopped taking medicines was side effects (14.8%). In contrast, the
most common reason given for stopping medicine intake by those getting their
medicines from the private sector was the cost of drugs (15.5%). The next most
common reasons for stopping anti-TB medications among those treated in the private
sector were related to the TB medications themselves. These included side effects,
cost and size of pills. Health service delivery issues and access issues did not appear
to be major reasons for stopping medicine (11.1% and 6.8%, respectively). There were
no statistically significant differences in the proportions who were non-adherent and
the reasons for non-adherence in terms of sex, age, or urban/rural classification.

Among the survey cases, 81 had previous TB treatment, including 4 who were
currently on treatment and with previous treatment before 2011. However, details of
treatment were not available for the 40 participants who had previous treatment before
2011. Of the 41 participants with previous treatment after 2010, 15 stopped taking their
medications (9 from a DOTS clinic; 6 from a private clinic). Ten of the 15 participants
who defaulted during their previous TB treatment were smear-positive and were
classified as TB cases during the survey, 3 of whom were rifampicin- resistant on Xpert
MTB/RIF.

14
Breakdown regarding provision of anti-TB drugs in terms of urban/rural classification not shown. Data
available on request.
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 Table 61. TB care provided to survey participants with previous TB treatment
in 2011 onwards, by sex, 2016 NTPS, Philippines (N=989)

Male Female Total

Characteristic
No. % No. % No. %
TB treatment (on or after 2011)a 616 3.0 373 1.4 989 2.1
Ever had sputum examinationb 527 87.2 308 82.6 845 85.4
Results of sputum examinationc
Negative 101 18.8 73 23.7 174 20.6
Positive for TB 384 71.5 196 63.6 580 68.6
Don’t know results 52 9.7 39 12.7 91 10.8
Ever had chest X-rayb 537 87.2 334 89.5 871 88.1
Chest X-ray resultd
Normal 26 4.8 22 6.6 48 5.5
TB 469 87.3 277 82.9 746 85.6
Other conditions (pneumonia,
pleural effusion, emphysema,
non-specific conditions) 11 2.0 7 2.1 18 2.1
Don't know results 31 5.8 28 8.4 59 6.8
Given anti-TB medicineb 586 95.1 356 95.4 942 95.2
Source of medicinese, f
Public sector only 467 79.7 271 76.1 738 78.3
Rural Health Unit/ urban health
center/ DOTS TB clinic 456 77.8 268 75.3 724 76.9
Provincial hospital and other
public health facilities 17 2.9 6 1.7 23 2.4
Private sector only 112 19.1 81 22.8 193 20.5
Private pharmacy 80 13.7 56 15.7 136 14.4
Private clinics, hospitals, NGO &
other private health facilities 39 6.7 29 8.1 68 7.2
Other sources (relatives/friends,
unspecified health facility, PPM
DOTS) 2 0.3 2 0.6 4 0.4
Both public and private health
facilities 4 0.7 2 0.6 6 0.6
No data 1 0.2 0 0.0 1 0.1
a Excludes participants currently on treatment and those treated on or before 2010; percentage calculated over
total females (n=25,737) or total males (n=20,782)
b Percentage calculated over participants who had treatment on or after 2011
c Percentage calculated over participants who ever had sputum examination on or after 2011
d Percentage calculated over participants who ever had chest X-ray on or after 2011
e Percentage calculated over participants who were given anti-TB medicines
f Multiple responses accepted

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 Table 62. Adherence to TB treatment and reasons for stopping medications
among survey participants with previous TB treatment in 2011
onwards, by sex, 2016 NTPS, Philippines (N=162)

Male Female Total

Characteristics
No. % No. % No. %
Stopped taking medicinesa 104 17.7 58 16.3 162 17.2
Reason for no longer taking medicineb, c
Drug-related 42 40.4 24 41.4 66 40.7
Side effects felt 21 20.2 12 20.7 33 20.4
Cost of drugs 19 18.3 9 15.5 28 17.3
Pill related (Too many pills; size of pills) 2 1.9 4 6.9 6 3.7
Behavioral 43 41.3 17 29.3 60 37.0
Forgot to take drugs 22 21.2 12 20.7 34 21.0
Felt better; symptoms relieved 16 15.4 4 6.9 20 12.3
Don't like to take medications 2 1.9 1 1.7 3 1.9
Failed to get medications from the health
center 3 2.9 0 0.0 3 1.9
Health service delivery-related 12 11.5 6 10.3 18 11.1
Health center-related (no available drugs,
no staff in health center, health center
closed) 8 7.7 3 5.2 11 6.8
Advised by doctor/health care provider 3 2.9 2 3.4 5 3.1
Chest X-ray reading normal 1 1.0 1 1.7 2 1.2
Access issues 7 6.7 4 6.9 11 6.8
Transferred residence 3 2.9 4 6.9 7 4.3
Distance of home to source of
drugs/facilities 4 3.8 0 0.0 4 2.5
Physiological reasons 0 0.0 7 12.1 7 4.3
Pregnancy 0 0.0 6 10.3 6 3.7
Had another disease/medical condition 0 0.0 1 1.7 1 0.6
Others (work-related reasons, smoking,
calamities/disasters) 4 3.8 1 1.7 5 3.1
No data 1 1.0 0 0.0 1 0.6
a Percentage calculated over participants who were given anti-TB medicines
b Percentage calculated over participants who stopped taking medicine
c Multiple responses accepted

5.7. Risk factors for TB

Table 65 shows the risk factors independently associated with being a survey case
(see Section 4.12.3 for details on the multivariable logistic regression model). Age was
a significant risk factor, with the risk for having TB increasing with age. Using the 15–
24 age group as the reference, the risk of having TB was highest in the age group ≥65
(adjusted OR, or aOR=2.8, 95% CI: 1.8−4.4). Other risk factors were: previous TB
treatment (aOR= 2.3, 95% CI: 1.1−2.6), having diabetes mellitus (aOR=1.7, 95% CI:
1.1−2.6), and residents in an urban setting (aOR=1.6, 95% CI: 1.2−2.0).
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Smoking and sex were analyzed as variables that were interacting with each other
because the test was significant between these two variables. The risk among men
further increased among smokers and more pack-years, with the highest risk observed
among men with more than five pack-years smoking history (aOR=3.3, 95% CI:
2.7−4.1). Women with 1−5 pack-years of smoking also had an increased risk
(aOR=1.9, 95% CI: 1.3−2.7).

Surrogate indicators for socio-economic status that were significantly associated with
TB were: being enrolled in the 4Ps conditional cash program (aOR=1.6, 95% CI:
1.2−2.1). Ownership of a refrigerator and household size were analyzed together due
to significant interaction between these two variables. The risk increased by 1.7 times
among households without a refrigerator compared to those with a refrigerator,
regardless of the household size. The difference in risk occurred among those who
owned a refrigerator. Absence of health insurance coverage was also significantly
associated with TB (aOR=1.8, 95% CI: 1.4−2.3).

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 Table 63. Risk factors for pulmonary tuberculosis among survey participants, 2016 NTPS, Philippines (N=46,689)

Crude
Adjusted distribution of
distribution of Adjusted
Characteristics survey casesa SEa (OR) 95% CIa P valuea
survey cases ORa
(%)
No. (%)
Age group (years)
15–24 72 (0.6) 0.7 1.0 - - -
25–34 68 (0.8) 0.8 1.2 0.2 0.8–1.6 0.414
35–44 76 (0.9) 1.0 1.5 0.3 1.0–2.1 0.055
45–54 103 (1.4) 1.6 2.2 0.4 1.6–3.2 < 0.001
55–64 73 (1.3) 1.4 2.2 0.5 1.5–3.4 < 0.001
≥ 65 74 (1.6) 1.6 2.8 0.6 1.8–4.4 < 0.001
Urban/ rural classification
Rural 222 (0.9) 0.9 1.0 - - -
Urban 244 (1.1) 1.2 1.6 0.2 1.2–2.0 < 0.001
Previous TB treatment
No 389 (0.9) 0.9 1.0 - - -
Yes 77 (3.0) 3.1 2.3 0.4 1.7–3.1 < 0.001
Self-reported diabetes mellitus
No 428 (1.0) 1.0 1.0 - - -
Yes 38 (2.0) 2.1 1.7 0.4 1.1–2.6 0.014
4Ps recipient
Not a 4P recipient 335 (1.0) 1.0 1.0 - - -
4Ps recipient 129 (1.2) 1.2 1.6 0.2 1.2–2.1 0.0001
Health insurance coverage
With insurance 262 (0.9) 0.9 1.0 - - -
Without insurance 204 (1.2) 1.3 1.8 0.2 1.4–2.3 < 0.001

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 Crude
Adjusted distribution of
distribution of Adjusted
Characteristics survey casesa SEa (OR) 95% CIa P valuea
survey cases ORa
(%)
No. (%)
Sex and smoking
Females who are non-smokers 96 (0.5) 0.4 1.0 - - -
Females who are 1 to 5 pack years
smokers 34 (0.9) 0.9 1.9 0.4 1.3–2.7 0.001
Females who are more than 5 pack
years smokers 1 (2.7) 2.7 4.0 4.3 0.5–33.6 0.199
Males who are non-smokers 57 (0.9) 0.9 2.3 0.4 1.6–3.3 < 0.001
Males who are 1 to 5 pack years
smokers 199 (1.5) 1.5 3.3 0.4 2.7–4.1 < 0.001
Males who are more than 5 pack
years smokers 15 (2.6) 2.5 3.5 1.0 1.9–6.3 < 0.001
Household size * with refrigerator
1-4 * with refrigerator 42 (0.6) 0.7 1.0 - - -
1-4 * without refrigerator 166 (1.3) 1.3 1.7 0.3 1.2–2.5 0.003
5-8 * with refrigerator 50 (0.6) 0.6 0.9 0.2 0.5–1.3 0.455
5-8 * without refrigerator 166 (1.2) 1.2 1.7 0.3 1.1–2.5 0.010
≥9 * with refrigerator 9 (0.5) 0.5 0.6 0.3 0.2–1.5 0.273
≥9 * without refrigerator 31 (1.2) 1.2 1.7 0.5 1.0–2.9 0.068
a Estimated using survey logistic regression, with stratified cluster design and accounting for inverse probability weights

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6. Discussion

6.1. TB prevalence estimates

Based on the 2016 NTPS, the burden of PTB in the Philippines is high, and higher
than previously estimated from routine surveillance notifications and projections.
Based on the bacteriologically confirmed PTB prevalence rate derived from the survey,
around 760,000 Filipinos are estimated to have PTB. Projected to all ages and all
forms of TB, around 1 million Filipinos are estimated to have TB. The PTB prevalence
rate in the adult population of 1,159 per 100,000 population is almost 2.5 times the
reported PTB prevalence rate of 397 per 100,000 for 2015, based largely on routine
registry reports [WHO 2016a].

Comparing results from the last two national surveys in the country, there is no
evidence to suggest that culture-confirmed PTB prevalence in 2016 has significantly
changed from that estimated in 2007. Although the survey was designed to provide a
point estimate of PTB prevalence for 2016, the survey did not have sufficient statistical
power to detect small significant differences between the two time points; nonetheless
there is enough assurance that there has not been a decline in prevalence between
2007 and 2016.

The bacteriologically confirmed PTB prevalence rates for the four strata are also high,
but again, the survey was not powered enough to detect statistically significant
differences among the strata. However, stratum 1 appears to have a higher prevalence
(which consists predominantly of urban clusters) compared to stratum 4 (with
predominantly rural clusters). More striking, however, is the sex differential in PTB
prevalence: men have a bacteriologically confirmed PTB prevalence that is 2.7 times
higher than women. Although similar to other maturing TB epidemics in Asia, where
prevalence also increases with age, the rates are still considerably high in the young
age groups, implying high transmission in the community.

Data from the 2016 NTPS provides the best basis to date to estimate the true burden
of TB disease in the country, having been derived from a representative sample of the
Philippine population. In addition, The Philippines is only the third in the world (after
Kenya and Bangladesh) to systematically use Xpert MTB/RIF for all positively-
118
screened participants as an additional diagnostic tool for a national TB survey and with
comparable survey methods, as recommended by the World Health Organization
[WHO 2011]. The NTPS conducted in Kenya in 2015─2016 found a prevalence for
bacteriologically confirmed PTB of 558 per 100,000 (95% CI: 455─662)—higher than
a previous prevalence estimate for 2015 of 255 per 100,000 (95% CI: 134─414)
[Sitenei 2016, personal communication, 25 October]. However, the NTPS in
Bangladesh yielded a prevalence for bacteriologically confirmed PTB of 287 per
100,000 (95% CI: 244─330), which was within the 95% confidence interval of the pre-
survey estimate [Rahman 2016, personal communication, 25 October]. On the other
hand, even without the use of the highly sensitive Xpert MTB/RIF to test all positively-
screened survey participants, at least six out of 19 countries that had carried out
national TB prevalence surveys between 2009 and August 2016 found TB prevalence
rates that were significantly higher than pre-survey estimates based on routine
surveillance data [WHO 2016a].

6.2. Reasons for the high TB burden

There are multiple factors to explain the high prevalence of TB in the Philippines: social
determinants of health and disease, demand-side factors, and supply-side factors,
including health systems weaknesses (Fig. 24).

Figure 24. Multiple factors leading to the high TB burden

119
The social determinants of TB are key drivers for the endemicity of TB in the country.
A WHO study of 134 countries on trends in TB incidence found that biological and
socioeconomic determinants were more strongly associated with TB transmission
than direct outcomes of TB control programs, at least in the first decade of this
millennium [Dye et al. 2009]. In the Philippines, the incidence of poverty has not
declined substantially from 2006 to 2015 (21% to 16.5%), and with the unchecked
population growth, the number of poor families has remained almost the same (3.8
million in 2006 and 3.75 million in 2015) [Philippine Statistics Authority, 2017].
Similarly, the Human Development Index (HDI)—a composite measure of health (life
expectancy at birth), knowledge (mean years and expected years of schooling), and
income (gross national income per capita)—has improved by only 8% from 2006 to
2015 (0.63 to 0.68) [United Nations Development Programme 2016]. Inequities
continue to adversely affect the poor, marginalized, and ethnic minorities most. The
Inequality-adjusted HDI (IHDI), an index introduced in 2011, showed a slight
improvement of only 8% from 2011 to 2015 for the Philippines (0.516 to 0.556) [UNDP
2016]. Sustained TB control and elimination can only be fully realized with human
development—hence the need to relate target 3.3 on TB with the overarching goal of
the SDGs.

On the demand side of health care, the health care-seeking behavior of symptomatic
individuals does not appear to have improved. The proportion of people self-
medicating for symptoms suggestive of TB was similar in the 2007 and 2016 surveys
(43.4% and 40.1% in 2016), but the proportion taking no action for symptoms was
much higher in the 2016 survey (41%) compared to the 2007 survey (25%) [TDF &
DOH 2008]. In addition, more individuals consulted a healthcare worker in 2007 (32%)
compared to 2016 (19%), but the proportion going to public providers improved from
54.2% to 67.0%. (Fig. 25)

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 Source for 2007 NTPS data: TDF and DOH, 2008

Figure 25. Comparison of health-seeking behavior pattern described in the

national TB prevalence surveys in 2007 and 2016, Philippines

The most common reasons for taking no action or self-medicating are similar in both
surveys: symptoms not considered significant enough to warrant consultation, costs
involved for travel and missed work, and time constraints. A qualitative study of the
poor in highly urbanized areas showed similar perceptions of cough being “normal”,
and work-related constraints in seeking care [Reyes & Amores 2014].

Among those who were previously treated for TB, the 2016 survey revealed that
utilization of public providers (based on the source of anti-TB drugs) was higher than
private providers (78.3% and 20.5%, respectively). However, adherence to treatment
was an issue for 17%, mainly because of drug-related issues (such as adverse drug
reactions, drug costs) and behavioral issues (such as forgetting to take drugs, feeling
well). Poor drug adherence contributes to the persistence of TB in the community and,
of even greater concern, the rise of drug-resistant TB. The high proportion of non-
adherence to treatment, albeit from self-reported information from the 2016 NTPS
participants, appears to be discordant with the reported treatment success rate of 92%
for 2014 [WHO 2016a] and suggests problems with case notification and monitoring.

121
There must be good quality and patient-centered options for tailoring optimal treatment
for those with adverse reactions to anti-TB drugs and for motivating patients to initiate
and complete treatment, especially among those who are asymptomatic (26% among
the survey TB cases) or who feel better after a few weeks. Costs of care among those
who prefer private providers, as well as travel costs and work lost even for those who
go to the public sector, are also important reasons for poor adherence. These findings
suggest a need for vigorously increasing awareness on TB and improving help-
seeking behavior, developing effective ways of social protection for the poor, and
testing various social enterprise models for affordable care in the private sector.

In relation to supply side issues, the 2016 Joint Review of the TB Program provided a
comprehensive review of the many achievements of the TB control and care efforts in
the Philippines, but also outlined huge challenges in addressing the following areas:
health systems support (financing, human resources, supply management,
information systems), integrated service delivery, equitable and patient-centered care,
and prevention efforts [DOH 2017]. A deep layer of TB was uncovered underneath the
TB iceberg surface with the use of more sensitive screening and diagnostic tools for
the 2016 NTPS. The 2016 NTPS findings underscore some of the supply-side reasons
why a huge TB burden persists, among them:

 Reliance on passive case detection and using traditional diagnostic tools such as
light microscopy—only 6% of the NTPS population had screening symptoms, and
most had not consulted for these symptoms, resulting in delayed or missed case
detection and treatment. In addition, passive case detection will not reach the
contacts of TB cases for screening and prophylaxis measures.

 Barriers to accessing health facilities and quality patient-centered care—various

reasons were cited by NTPS participants: distance, travel costs, inconvenient clinic
hours for employed persons and students, and drug stock-outs. In addition, around
11% of those who had previous TB treatment reported that they did not know the
results of their sputum examination or chest X-ray.

 Insufficient targeting of high-risk groups for active case detection—the NTPS

identified several risk groups, for example:
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 o Male smokers: the 2015 Global Adult Tobacco Survey estimated that there
were around 14 million adult male smokers in the Philippines, with the
highest proportions found among those aged 45─64 years and the lowest
quintile of the household wealth index [DOH & PSA 2015].

o Persons with diabetes mellitus: the prevalence of diabetes was around 5.8%
in 2015, and the number of Filipinos with diabetes is predicted to increase
from 2,770,000 in the year 2000 to 7,798,000 in 2030 [WHO 2016b].

o Poor households: in 2015, the poverty incidence was 16.5%15, with an

estimated 3.75 million poor families [PSA 2017]

 Insufficient private sector engagement in quality care—the survey found that

around one-third of those with symptoms suggestive of TB still preferred to consult
a private provider, while one-fifth of those who had previous TB treatment obtained
their anti-TB drugs from private outlets like pharmacies and clinics. The extent to
which these private providers provide quality care, encourage adherence to anti-
TB treatment, undertake contact tracing, and treat latent TB is not systematically
monitored. In the 2016 NTPS, survey participants who were previously treated by
a private provider were less likely to have had a sputum examination and/or a chest
X-ray.

The supply side also faces significant measurement issues. Without a comprehensive
information system and an effective notification system for TB diseases and TB-related
mortality, the information used for monitoring the program and evaluating the impact
of TB efforts on TB burden can be compromised. Although case notification rates in
the country have been increasing (Fig. 26), the prevalence to notification ratios (P:N
ratios) across all age groups are still high (Fig. 27). For smear-positive PTB as reported

15 Proportion living below the poverty threshold, which is the minimum income/expenditure required for a
family/individual to meet the basic food/nutrients and non-food requirements such as clothing, housing,
transportation, health, and education expenses. In 2015, the annual per capita threshold was PhP 21,753 (PhP
25,007 in the National Capital Region). [PSA 2017]
123
to the NTP registry in 2016, the highest P:N ratios were in the age groups 15–24 (4.2)
and 45–54 years (3.3), and among men (3.3).

Figure 26. Incidence and case notification rates in the Philippines, 2000–2015

Figure 27. Ratio of prevalence to case notification, 2016 NTPS, Philippines

Republic Act No. 10767, otherwise known as the “Comprehensive Tuberculosis

Elimination Plan Act” and enacted in April 2016, requires notification of TB cases, but
the implementing rules and regulations to enforce such a provision, particularly among
private practitioners, are not yet in place. In the 2016 NTPS, there were 170 survey
participants who claimed that they were “currently on treatment” at the time of the
survey. However, only 84 (49.4%) could be traced in the Integrated TB Information
124
System of the NTP. Of those who could be traced in the TB registry, 94% were
reported by public providers, underscoring poor notification by private providers.

6.3. TB screening and diagnostic tools

The sample size estimation for the 2016 NTPS was based on an expected prevalence
rate of 2.6 per 1,000 for smear-positive PTB and 5.8 per 1,000 for bacteriologically
confirmed PTB. This survey detected more than the expected number of survey cases
by a combination of new (Xpert MTB/RIF), improved (DSSM by LED fluorescent
microscopy and digital chest X-rays), and traditional (symptoms of cough of ≥2 weeks
and/or hemoptysis) screening and diagnostic tools.

The sensitivity of symptoms of cough of ≥2 weeks duration, hemoptysis, or both was

only 32.2% for detecting survey prevalent cases (refer to Table 43). Using cough of
any duration and/or hemoptysis increases the sensitivity rate to 58.8%. Thus, using
symptoms alone for screening will miss one-third to two-thirds of TB cases. As a
screening tool in active case detection in general settings, neither is it helpful by itself
because of the high number of individuals with false-positive results, but it may be of
some value in congregate settings or in high-risk groups.

On the other hand, chest X-ray screening with interpretation done in the field (where
over-reading was encouraged in the survey) had a sensitivity of 98.2% (refer to Table
44). The combined sensitivity of symptom screening (using cough ≥2 weeks duration
and/or hemoptysis) and chest X-ray done in the field was 100%16 (Table 42). Thus,
doing chest X-rays, with or without symptom screening, is an appropriate option for
TB screening because of its high sensitivity. However, in a general setting, the number
needed to screen with chest X-rays to detect one PTB case would be relatively high17.

16 Excludes 18 who were interviewed for symptoms but did not have a chest X-ray.
17 A total of 430 out of 41,333 (1.04%) chest X-rays belonged to survey TB cases, based on results of chest X-rays
read by the field team leader and/or off-site radiologist (Table 44). The inverse of 1.04% is 96, meaning the
number needed to screen with chest X-rays to detect one PTB case is 96.

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Chest X-ray is more useful for congregate or clinical settings where the number
needed to screen to detect one TB case would be lower. Targeting risk groups for
more intensive case finding, treatment, and prevention efforts can be a good strategy
for prioritizing interventions where resources are limited. This survey found several
factors associated with TB, namely: the older age groups—notably those ≥65 years,
males, and diabetes mellitus, smoking—particularly heavy smokers, poverty, and
living in an urban setting. It would be useful to conduct further studies on the cost-
effectiveness of chest X-ray screening among these risk groups and in individuals at
high risk for TB from a combination of risk factors.

The above findings from the 2016 NTPS are consistent with the pooled sensitivity rates
estimated in a systematic review of various screening tools and algorithms [WHO
2013a]. For prolonged cough, the pooled sensitivity was 35% (95% CI: 24─46%), while
that for chest X-ray suspicious for TB was 98% (95% CI: 95─100). The systematic
review also estimated pooled specificity rates of 95% (95% CI: 93─97%) for prolonged
cough and 75% (72─79%) for X-ray finding compatible with TB. It acknowledged,
however, that there was substantial heterogeneity among the studies included in the
review, and that the number needed to screen (and cost-effectiveness) would vary
with the prevalence of TB and risk factors, chest X-ray reader variability, and costs ─
hence the need for cost-effectiveness analyses in the local context.

With regard to diagnostic tools, the sensitivity of DSSM, despite using LED fluorescent
microscopy, was only 36.7% but the specificity was 99.4%. The sensitivity in this
survey was comparatively low; a meta-analysis of LED-FM found a pooled sensitivity
of 66.9% (95% CI: 60.5─72.7%) and a pooled specificity of 96.8% (95% CI:
93.1─98.6%) [Chang 2016]. The performance of LED-FM was also low compared to
pooled estimates of sensitivity for conventional sputum smear microscopy at 61%
(95% CI: 31─89%) [WHO 2013]. This could be attributed to variability in the
performance of the medical technologists in the participating laboratories, particularly
because it was the first time for many of them to use LED-FM after undergoing training.
The heavy workload in the laboratories also led to delays in the reading of the smears,
although auramine staining was done shortly after receipt of the sputum specimens by

126
the laboratories. In general, the turn-around time for laboratories to provide Xpert
results was shorter (mean=5.7 days, range: 1─24) compared to LED-FM (mean=8.9
days, range: 1─89).

The added value of Xpert MTB/RIF in terms of the detection of M. tuberculosis was
well demonstrated in this survey, as shown by the higher proportions of Xpert-positivity
from culture-positive specimens that were smear-positive (85%) or smear-negative
(48%) compared to culture positivity from Xpert-positive specimens that were smear-
positive (71%) or smear-negative (21%) (refer to Tables 30 and 31). MTB culture as
the gold standard, showed a pooled sensitivity of 88% (95% credible interval: 84─92%)
and a pooled specificity of 99% (95% CrI: 98─99%) when using it as an initial
diagnostic test in lieu of DSSM. As an add-on test following a negative DSSM result,
the pooled sensitivity and specificity rates of Xpert MTB/RIF were 68% (95% CrI:
61─74%) and 99% (95% CrI: 98─99%), respectively [WHO 2013b].

In terms of the survey cases, there were an additional 238 that were identified by Xpert
MTB/RIF alone, compared to an additional 69 found by MTB culture alone. Variability
in terms of the laboratory performance, the cold chain, and transport time from the
field affected the yield from MTB culture (refer to Annex C-2). In contrast, the
automated, cartridge-based Xpert process and resilience of the MTB DNA allowed
better standardization and faster turn-around times, in addition to its ability to screen
for rifampicin resistance, which was 7.3% by Xpert MTB/RIF and 5.7% by standard
DST in the 2016 NTPS. The second national drug resistance survey on TB conducted
in 2012 showed a rifampicin-resistance rate of 4.64% (95% CI: 3.62─5.92%, with
missing value imputations) [DOH 2014b], but testing with Xpert MTB/RIF was not done
in the 2012 survey.

An updated policy guidance from WHO underscored the advantages of Xpert MTB/RIF
in improving case detection and to minimize delays in diagnosis and treatment.

6.4. Limitations of the study

The 2016 NTPS survey was organized by the DOH in such a way that there were
multiple layers of external monitoring and checks in addition to the internal quality

127
management procedures of the project implementation team. These mechanisms
were: the Survey Steering Committee, the Survey Technical Working Group, and
expert technical assistance from WHO staff and consultants. A midterm joint review
by these bodies also ascertained that the survey was being conducted according to
internationally accepted standards for prevalence surveys. Overall, the 2016 NTPS
survey provided nationally representative, precise and reliable estimates of the
prevalence of TB in the country. Nonetheless, there were several limitations in the
conduct of the survey. Additional lessons from the survey are found in Annexes C-1
and C-2.

6.4.1. Low participation rate

The survey did not reach the 85% target participation rate. Lower participation rates
were observed in the urban areas and among households in the higher income
brackets. Although the survey teams extended the survey hours for some days in the
week to the evenings or included Sundays in their survey schedules, these measures
could not catch all those with conflicting schedules.

More women than men and those in the older age groups had higher participation
rates. The low participation rates in men may be due to conflict in work, or school
schedules in the younger age groups. Since the prevalence of bacteriologically
confirmed cases among males was significantly higher and their participation rate was
lower, it is possible that some of the men who joined the survey felt sicker and more
motivated to join the survey.

Midway through the survey, upon agreement with the NTPS Technical Working Group,
house-to-house interviews were conducted to address the low participation rate. This
strategy yielded a significantly higher proportion of survey cases from those
interviewed at the survey site (440 out of 41,985, or 1%) compared to those visited in
their houses during mop-up operations (26 out of 4,238, or 0.6%), suggesting that
those visited during the mop-up operations could skew the prevalence estimates.
However, this group of individuals comprised only 9% of the entire survey population.
Moreover, although the survey did not reach the target participation rate of 85%, a
scatterplot analysis of the weighted cluster prevalence rates did not show a significant

128
 association between participation rates and prevalence rates (r=-0.07, P=0.46, Figure
28).
3
2
Prevalence (%)

1
0

20 40 60 80 100
Participation rate (%)

Figure 28. Scatterplot of weighted cluster prevalence and participation rates

In addition to the relatively low participation rate, the chest X-ray participation rate was
also relatively low (88%), especially among those who were visited at home during the
mop-up operations. Among the sputum-eligible population, only 87% submitted
sputum. However, missing data from these survey limitations were accounted for in
the estimation of prevalence rates through missing value imputations (see Section
4.17).

6.4.2. Inter-observer variabilities in CXR readings

It is recognized that the chest X-ray is a sensitive but non-specific diagnostic modality,
hence the survey had off-site radiologists and senior central radiologists to validate
the field interpretations. However, the inter-observer agreement beyond what is
expected by chance was fair to moderate only. This was because over-reading by field
team leaders was encouraged in the field to reduce the chances of missing TB cases.
To countercheck the X-ray readings in the field, off-site radiologists also interpreted
the X-rays within 48 hours to enable the field to call back participants with X-rays
suggestive of TB that were not picked up by the field team leader. For the adjudication
of TB cases by the Diagnostic and Medical Panel, the interpretation of the senior

129
central radiologists was considered as the final reading in deciding on the case
classification of the survey participants. All chest X-rays of participants with positive
laboratory results, all abnormal chest X-rays, discordant field readings, and 5% of
normal chest X-rays were reviewed at the central level by the senior radiologists.

6.4.3. Conditions affecting laboratory results

Laboratory performance was generally reliable in terms of standards for culture

recovery rates and sensitivity rates (see Table 38 and Annex C-2), except for one
laboratory. However, overall, culture for MTB under-performed compared to Xpert
MTB/RIF (refer to Tables 30─31), possibly due to field conditions affecting sputum
specimens and variability in the performance of the participating laboratories (refer to
Annex C-2). On the other hand, Xpert MTB/RIF could be detecting dead M.
tuberculosis, as indicated by positive results among 18 individuals who claimed to be
on treatment and yet had no symptoms of cough ≥2 weeks and/or hemoptysis (refer
to Table 47).

The high sputum eligibility rate, which led to a high volume of specimens than
previously estimated, led to heavy workloads in the laboratories. Logistic issues
related to maintaining cold storage during transport, contamination of media, and
inadequate volume/quality of sputum samples may have affected culture results (refer
to Annex C-2). However, regular monitoring visits and assessment of performance by
the QM team showed that the performance indicators were within the acceptable
range. Almost 90% of specimens for culture were processed within the recommended
5 days or less (Annex C-2), in contrast to the 2007 survey wherein only 68.5% of the
specimens were processed within one week. Blind, independent readings by a medical
technologist were done for all smear-positive and smear-negative slides.

6.4.4. Assessment of diabetes mellitus and HIV as risk factors for TB

Diabetes mellitus as a risk factor for TB was assessed based on self-reported history
only rather than actual blood sugar testing, which could have underestimated the
presence of DM in the survey population. Nevertheless, we still found a significant
association between self-reported diabetes and TB. The study protocol did not include
HIV screening among the participants, hence we were not able to do any analysis to
130
determine whether the rising incidence of HIV in the country (0.11 per 1,000 in 2016
from 0.05 per 1,000 in 2010 [UNDP 2017]) could have contributed to the high
prevalence of TB. Other factors not measured were: indoor pollution, floor area of
dwelling, and malnutrition.

6.4.5. Non-inclusion of children and other groups

The survey protocol excluded children <15 years old and congregate settings such as
schools, dormitories and prisons because the epidemiology and risk profile of TB in
these groups are hypothesized to be different from the general population and a
targeted set of interventions may be more cost-effective for these specific groups. In
addition, the survey did not include estimation for extrapulmonary TB.

6.4.6. Recall bias and stigma

It is possible that survey participants preferred not to disclose their symptoms and
history of treatment because of stigma or they could not recall accurately the details
of their treatment. Upon verification with the NTP coordinators, there were participants
who did not fully disclose their treatment history. There may also be inherent variability
in the way the field interviewers asked or probed on the questions related to symptoms
and treatment.

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7. Conclusion and Recommendations

“To raise new questions, new possibilities, to regard old problems from a new angle

requires creative imagination and marks real advances in science.”

Albert Einstein (1879─1955)

Ending TB as part of the Sustainable Development Agenda requires accurate

information for evidence-based program planning and action. The 2016 NTPS has
allowed us to measure the burden of TB more accurately, particularly with the use of
digital chest X-rays and Xpert MTB/RIF, which was not used in the 2007 NTPS. This
nationally representative, cross-sectional survey of 46,689 adult Filipinos shows that
TB remains a significant public health problem in the Philippines.

7.1. Main findings

7.1.1. TB burden

 The estimated prevalence rates of PTB among those ≥15 years were:

o Bacteriologically confirmed PTB: 1,159 per 100,000 population (95% CI:

1,016─1,301)

o Smear-positive PTB: 434 per 100,000 population (95% CI: 350─518)

o Culture-positive PTB: 587 per 100,000 population (95% CI: 488─687)

o Xpert-positive PTB was 983 per 100,000 population (95% CI: 856─1,110)

 The prevalence of PTB significantly increased with age and was higher among
males (1,713 per 100,000 population, 95% CI: 1,482─1,943) compared to females
(627 per 100,000 population, 95% CI: 516─739).

 Based on culture-positive PTB results, there was no evidence of a decline in the

PTB prevalence rates in the 2016 NTPS compared to the 2007 NTPS.

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7.1.2. Other key findings

 Around 1 million Filipinos are estimated to have tuberculosis, and may or may not
even know it.

 Around 760,000 Filipinos aged ≥15 years are estimated to have PTB.

 In addition to age and male sex as risk factors for TB, other significant risk factors
are: previous TB treatment, diabetes mellitus, smoking, indicators of poverty, and
urban dwellers.

 Screening and diagnosis:

o Screening for TB cases using symptoms alone (cough of ≥2 weeks and/or

hemoptysis) missed two-thirds of bacteriologically confirmed PTB cases.

o Chest X-ray screening detected almost all PTB cases, but the number
needed to screen to detect 1 TB case was 100 (430 detected out of 41,443
screened by chest X-ray). Among the bacteriologically confirmed cases, the
radiological abnormalities suggestive of PTB were varied: fibrohazy and/or
reticular lesions (90.4%), nodular lesions (22.7%), tracheal deviation
(19.1%), cavities (17.9%), and calcifications (4.6%)

o Two-thirds of bacteriologically confirmed cases were smear-negative.

Although culture remains the gold standard for TB diagnosis, under field
survey conditions, Xpert MTB/RIF detected 1.7 times more TB cases than
culture for M. tuberculosis.

o Rifampicin resistance was detected by Xpert MTB/RIF in 7.3% of 397 Xpert-

positive sputum samples. Any type of rifampicin resistance by DST of 230
culture-positive isolates was 5.6%, of which MDR-TB (RIF+INH) accounted
for 2.2%.

 Health care-seeking behavior:

o Only 6% of all survey participants had cough of ≥2 weeks, with or without

hemoptysis, at the time of the survey. However, 41% of those with these

133
 symptoms suggestive of PTB did not take action, while 40% self-medicated.
Only 19% consulted a healthcare worker, mostly in the public sector (67%).
Perceived triviality of symptoms, costs of drugs and travel, and work-days
lost were the main reasons for non-consultation.

o Three out of four survey participants who had previous TB treatment

sourced their anti-TB drugs from the public sector. One out of five patients
did not complete anti-TB treatment, mainly due to drug-related reasons,
such as side effects and cost of drugs, and behavioral reasons such as
forgetting to take their pills or feeling better during the course of treatment.

 Missing cases:

o The prevalence of TB is almost 2.5 times what has been previously

estimated from routine surveillance statistics. Specifically, the prevalence to
notification ratios for smear-positive pulmonary TB across all ages was 3.1,
with the highest ratios found in the age groups 15─24 (4.2) and 45─54 (3.3),
and among men (3.3).

o One-half of survey participants who claimed to be on anti-TB treatment at

the time of the survey were not found in the national TB registry. Those
reported to the TB registry were mostly treated by the public sector.

7.2. Program implications and recommendations

The reasons for the high TB prevalence are multi-factorial: supply-side and health
systems weaknesses, demand-side factors like health-seeking behavior, and
associated health problems such as smoking and diabetes mellitus. Most importantly,
persistence of poverty and worsening inequities continue to fuel the spread of TB and
to undermine control efforts.

As such, eliminating TB must be a national and multi-sectoral priority. To reach target

3.3. of the Sustainable Development Goals will require urgent and sustained actions
at the national and local levels. PhilSTEP1 for 2017─2022 has been drafted with
ambitious goals to reduce TB incidence by 90% and mortality by 95% in 2035.
Considering that the 2016 NTPS has contributed important information towards a new
134
baseline against which PhilSTEP1 strategies will be measured, a major rethink of
actions at the national and local levels is required. The recommendations below are
directly related to the key findings of the 2016 NTPS and are intended to inform the
next stage of development of PhilSTEP1.

7.2.1. Short-term recommendations

Do systematic screening for TB among high-risk and vulnerable groups. Over

the short term, the prime imperative is to develop effective strategies to find the
missing TB cases and draw them in early as partners in the cascade of care. Priority
should be given to those most at risk: men, older age groups, the poor and urban
dwellers, smokers, those previously treated for TB, and those with diabetes mellitus.
Active case finding for high risk groups should be explored. It should be noted that the
2016 NTPS also had information gaps as a result of the survey’s exclusion criteria,
e.g., TB in children, TB in congregate settings, and TB among people living with HIV—
they too will require special attention by the TB program.

The dragnet to search TB cases needs a wide band. As observed in the post-survey
follow-up of TB cases, there are also leaks in the health care system with respect to
contact tracing and prophylactic treatment, especially among the children and other
vulnerable individuals in the households of TB cases. Without attention to early case
identification and treatment and contacts screening, the transmission cycle of TB is
perpetuated and TB is unlikely to be eliminated.

The tools to find the missing cases must be sharpened and enhanced. Chest X-
ray screening among identified high-risk groups will enhance the yield of traditional
screening methods. Cost-effectiveness analyses to determine the risk threshold levels
for employing chest X-ray screening in various settings should also be done.

The 2016 NTPS findings reinforce the merits of the PhilSTEP1 plan to scale up the
use of rapid and diagnostic tests, such as Xpert MTB/RIF, in presumptive TB cases
as a first-line diagnostic tool to identify TB cases and detect rifampicin resistance.
While culture for MTB is still the gold standard for TB diagnosis and is required for
DST, the feasibility, rapidity, robustness, and accuracy of Xpert MTB/RIF can
contribute to the reduction of pre-treatment loss to follow-up, allow timely
135
commencement of treatment, almost triple the TB cases found in comparison to smear
microscopy, and identify MDR-TB cases early. The use of new technologies should,
however, be coupled with skills training, continuous quality improvement, regular
supply and distribution of cartridges, and quality surveillance mechanisms.

Develop innovative behavioral interventions and enablers to improve health

care seeking and adherence to treatment. Addressing behavioral barriers to
healthcare-seeking is central to finding missing TB cases. Low risk perception, poor
knowledge on symptoms suggestive of TB, low trust in the health system, and low
treatment adherence can be addressed through innovative behavior change
communications coursed through motivated community-based and local change
agents such as local pharmacists, work-based clinics, and “click bait” apps through
social media. These messages cannot be “one-size-fits-all” approaches; different risk
groups and stakeholders will require tailor-fit approaches.

On the other hand, enablers to overcome external barriers such as costs, distance,
and work-days lost should be explored, e.g. incentives for positive behavior among
4Ps households, “walk-in” stations with flexible hours in communities and at work, and
social contracts with community-based organizations for improved outreach.

Reinvigorate and transform public-private-mix (PPM) partnerships.

Existing PPM partnerships should be reassessed to determine what has worked and
improve on what has not worked. Low notification of TB cases managed by private
providers must be addressed by the development of user-friendly apps for reporting
to the TB registry, considering the creation of social contracts for upscaling case
detection and care services, and exploring approaches to overcoming barriers such
as stigma and lack of confidence in the public sector. Close engagement with
professional medical and paramedical societies is needed to ensure effective
implementation of the provision on mandatory notification of TB cases, as stated in
Republic Act No. 10767.

Strengthen the collaboration between the National TB Control Program and

other health programs. A fully integrated TB service can maximize the identification
of presumptive TB, enhance case-finding, and foster integrated patient-centered care.
136
Examples where strengthened collaboration will be synergistic are: HIV-TB testing and
treatment, diabetes clinics, healthy lungs and smoking cessation programs.

7.2.2. Long-term recommendations

Given the magnitude of the current TB burden, the level of effort required to eliminate
TB requires significant escalation. The poor and disadvantaged require adequate
social protection strategies and increased PhilHealth TB benefit packages to reduce
catastrophic costs associated with TB, especially MDR-TB.

More vigorous advocacy is needed to increase local, national, and international

investments to address the burden of TB in the Philippines.

The human resources requirements alone to mount an intensified and effective

response against TB are formidable, considering the vast pool of TB disease and
infection in the country. Recommendations for wide use of chest X-ray screening and
scale-up of Xpert MTB/RIF (or next-generation molecular tests) present massive
logistics and supply management challenges, not to mention the significantly
increased requirements for anti-TB drugs for the anticipated half-a-million incident
cases per year. Similarly, investments for an efficient Integrated TB Information
System will need to be increased to improve TB surveillance in both public and private
sectors and to provide timely and accurate monitoring and feedback.

Most importantly, the greater focus on quality patient-centered and community-based

strategies will require reeducation and constant retooling of public and private
healthcare providers to achieve significant impact on TB outcomes. There is also a
huge imperative over the long term to ensure that contact tracing and prevention
efforts are effectively implemented, especially among vulnerable populations such as
children and the elderly.

At the most fundamental level, eliminating TB will require more comprehensive and
sustained poverty alleviation efforts and multi-sectoral partnerships at the national and
local levels.

137
7.3. Proposed research studies

Several studies and research questions have emerged from the 2016 NTPS findings
and are recommended for inclusion the PhilSTEP1 research agenda:

 A qualitative study of missing TB cases seen in the 2016 NTPS (perceptions and
experiences on health-seeking behavior of bacteriologically confirmed TB cases;
barriers & facilitators influencing health-seeking behavior; public vs private provider
preferences)

 Patient care pathway analysis among bacteriologically confirmed cases and

household contacts; contact tracing; quantitative study of health-seeking behavior

 Cohort/follow-up study of 2016 survey participants whose chest X-rays were

suspicious for TB but not bacteriologically confirmed to determine TB incidence
and health-seeking pathways

 Comparison of cluster-based prevalence vs actual case notifications in selected

clusters

 Assessment of TB under-reporting through an inventory study

 Follow-up study of young males in the study for provider-initiated counseling and
testing for HIV

 Operational research to improve: (1) TB case notification; (2) TB mortality reporting

 Operational research on role of DOTS clinics and private providers in case

detection and treatment and develop and test new models of public-private mix
partnerships

 Cost-effectiveness studies of various strategies for scaling up chest X-ray

screening (targeted vs general screening)

 Cost-effectiveness analysis of patient-centered drug-susceptible (DS) TB and

multidrug-resistant (MDR) TB care

138
 Risk scoring system for TB, validation, and development of apps to increase
awareness of TB risk among risk groups

 Development of a scoring system for symptoms suggestive of TB and validation of

the tool

 Review of chest X-ray patterns suspicious for TB, towards the development of
computer-assisted diagnosis

 Lab-based researches emerging from the 2016 NTPS:

 Genotyping of DS─ and DR─TB

 Description, speciation, and prevalence of NTM (by strata and by reference

laboratory)

 Scraping of smears (S2 morning specimen) to do Xpert or PCR-based detection of

MTB among survey participants with chest X-rays suspicious for TB but who were
not bacteriologically confirmed

139
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