菲律賓抗藥性結核病的前進方向

資料來源：http://www.thelancet.com/infection / Vol 22 June 2022 / 財團法人台灣紅絲帶基金會編譯

Dean 及其同事強調了 COVID-19 大流行對耐藥結核病診斷和治療的影響，導致病例報告率和接受耐藥結核病治療的患者人數減少。菲律賓是東南亞的一個中低收入國家，約有 100 萬人患有肺結核，大流行造成的衛生服務中斷嚴重影響了耐藥結核病的發生率通報——菲律賓是全球估計耐藥結核病發生率與接受治療的人數之間存在著 70% 的差距的十個國家之一。 在全國範圍內，只有 57% 的新診斷結核病病例有藥物敏感性測試結果。 

使用 Xpert MTB/ XDR（註1） 進行早期檢測最近被整合到菲律賓的耐藥結核病診斷操作中，因為它的複雜性低，可以在外圍實驗室進行分散式和擴大的篩查。然而，由於數字監測系統不足，無法連接患者的臨床數據，並允許其轉診至隨後的衛生設施進行治療，導致這些檢測的實施受到了阻礙。此外，缺乏 Xpert 試劑盒和較長的周轉時間導致了高失訪率，尤其是在基於社區的計畫中。尚未建立對中斷治療患者的支持，這導致耐藥結核病的流行。 

菲律賓患者在衛生籌資、基礎設施和勞動力方面均面臨耐藥結核病照護的重大障礙。國家結核病計畫資金嚴重不足，可用資源僅佔實際需求的 37%。值得注意的是，國家健康保險不涵蓋耐藥結核病治療、Xpert 或細菌培養。衛生保健系統也人手不足，大多數醫護人員駐紮在私立三級醫院。耐藥結核病熱點地區，特別是地理偏遠地區和監獄，在獲得耐藥結核病保健服務方面面臨更大挑戰。目前的耐藥結核病篩查僅覆蓋了一小部分高危和弱勢群體和測試服務。

我們同意 Dean 及其同事的觀點，亦即及時準確的流行病學監測對於解決耐藥結核病至關重要。在當地，需要建立哨點監測系統，並將新一代定序檢測納入全國抗藥結核病調查，以記錄當地耐藥模式。從基於紙張的記錄過渡到基於案例的數字監控系統將允許即時數據匯總和分析。透過預測分析和熱點映射的主動病例發現計畫將大大改善病例檢測。最後，加強患者轉診系統和強調對治療的順從性對於最大限度地減少對耐藥結核病新藥產生耐藥性至關重要。

Madeleine Nicole G Bernardo、Isabelle Rose I Alberto、Nicole Rose I Alberto、Michelle Ann B Eala、*Camilo C Roa Jr ccroa@up.edu.ph 菲律賓馬尼拉，菲律賓大學菲律賓總醫院，生理學系 (CCRJ) 和醫學院（MNGB、IRIA、NRIA、MABE )

（註1）Xpert MTB/XDR：一種 10 色反射測定法，適用於床旁環境，可直接從結核分枝桿菌陽性痰液 中檢測異煙肼、氟喹諾酮和二線注射藥物耐藥性。

The way forward for drug-resistant tuberculosis in the Philippines

http://www.thelancet.com/infection / Vol 22 June 2022

Dean and colleagues highlighted the effect of the COVID-19 pandemic on the diagnosis and treatment of drugresistant tuberculosis, resulting in reduced case notification rates and number of patients receiving treatment for drug-resistant tuberculosis. In the Philippines, a lower-middle-income country in southeast Asia where around a million individuals have tuberculosis, disruptions in health services due to the pandemic have severely affected the incidence notification of drug-resistant tuberculosis—the Philippines is one of ten countries accounting for 70% of the gap between the estimated global incidence of drug-resistant tuberculosis and the number of people enrolled in treatment. Nationally, only 57% of newly diagnosed tuberculosis cases have drug susceptibility testing results. 

Early detection with the Xpert MTB/ XDR assay was recently integrated into the Philippines’ drug-resistant tuberculosis diagnostic algorithm due to its low complexity, enabling decentralisation and scaled-up screening in peripheral laboratories.3 However, the implementation of these tests is hampered by insufficient digital surveillance systems that link patients and their clinical data and allow referral to subsequent health facilities for treatment.1 Furthermore, the lack of Xpert cartridges and long turnaround times have resulted in high rates of loss to follow-up, especially in communitybased initiatives. Support for patients with interrupted treatment has not been established, contributing to the prevalence of drug-resistant tuberculosis. 

Filipino patients face substantial barriers to drug-resistant tuberculosis care in terms of health financing, infrastructure, and workforce. The National Tuberculosis Program is crucially underfunded, with available resources amounting to only 37% of the actual need. Notably, the national health insurance does not cover drugresistant tuberculosis treatment, Xpert, or culture. The health-care system is also understaffed, with most healthcare workers stationed in private tertiary hospitals. Drug-resistant tuberculosis hotspots, particularly in geographically isolated areas and prisons, face greater challenges in accessing drug-resistant tuberculosis health-care services. Only a small proportion of high-risk and vulnerable groups are being reached with current drug-resistant tuberculosis screening and testing services. 

We agree with Dean and colleagues1 that timely and accurate epidemiological surveillance is central to addressing drug-resistant tuberculosis. Locally, there is a need to build sentinel surveillance systems and integrate next-generation sequencing into the national anti-drug-resistant tuberculosis surveys to document local resistance patterns. Transitioning from paper-based recording to casebased digital surveillance systems will allow real-time data aggregation and analysis. Active case-finding initiatives through predictive analytics and hotspot mapping will greatly improve case detection. Lastly, strengthening patient referral systems and emphasising adherence to treatment are crucial to minimising the emergence of resistance to new drugs for drug-resistant tuberculosis. 

We declare no competing interests. Madeleine Nicole G Bernardo, Isabelle Rose I Alberto, Nicole Rose I Alberto, Michelle Ann B Eala, *Camilo C Roa Jr ccroa@up.edu.ph Department of Physiology (CCRJ) and College of Medicine (MNGB, IRIA, NRIA, MABE), Philippine General Hospital, University of the Philippines, Manila 1000, Philippines