Current Situation in Control Strategies and Health Systems in Philippines by ERNESTO d’J. YUSON MD, Thalassemia Center of the Philippines, Balikatang Thalassaemia

1. PHILIPPINES
ERNESTO d’J. YUSON, M.D.
Thalassemia Center of the Philippines
Balikatang Thalassemia

2. DEMOGRAPHIC DATA
• POPULATION - 92-95M
• ETHNIC GROUPS: Chinese, Malay,
y
Spanish
• ANNUAL BIRTH RATE:
• AVERAGE INCOME: Php 14, 676
(
(USD 349.00) per capita
)p p
• EMPLOYMENT RATE: 39.4%
• NATIONAL HEALTH BUDGET: Php 3.2T
3 2T
(USD 7.27B)

3. DEMOGRAPHIC DATA
(National Statistics Office)
Population (August 2007) 88.57M
88 57M
Projected Population (2010) 94.01M
Inflation Rate (Aug 2011) 4.7%
Balance of Trade (June 2011) $ -376M
Exports (July 2011) $ 4.430B
Imports (June 2011)
I t (J $ 4 503B
4.503B
Unemployment (July 2011) 7.1%
Underemployment (July 2011) 19.1%
Simple Literacy (2000) 92.3%
Functional Literacy (2008) 86.4%
Average Family Income (2009) Php 206,000 ($4790)
GNP (Q4 2010) Php 2,760.1B
GDP (Q4 2010) Php 2 421 9B
2,421.9B

4. DEMOGRAPHIC DATA
• POPULATION (2007) 709 people per sq k
l km
• Annual Population Growth rate (2000-2007):
p ( )
3.2%
• Average births per woman/ total fertility rate (2003)
3.2%
• N d f f il planning: 16%
Need for family l i
• Infant mortality rate (2006): 20 infant deaths per
1,000 live births

5. HEALTH SYSTEM
• PUBLIC / GOVERNMENT:
• PRIVATE SECTOR:
• RE-IMBURSEMENT POLICY: PhilHealth,
(HMOs, Personal & F il I
(HMO P l Family Insurance)
)
• SPECIAL POLICIES O CHRONIC
S C O C S ON C O C
ILLNESS – NONE YET
• ANY SPECIAL POLICIES ON Hb d/o
d/o:
NONE YET

6. • Incidence of Beta thalassemia in the
Philippines is relatively low ( pp
pp y (approx <1%).
)
• The most common (approx 50%) mutation
is the “Filipino” deletion (b i i approximately
Filipino (beginning i t l
4Kb upstream of the B-globin gene and extending
beyond it)
• followed by the codon 67 (-TG) 26 percent
(Waye et al, 1994 K et al, 1998)
(W t l 1994; Ko t l

7. EPIDEMIOLOGY (TCP/ Ba-THa)
Ba THa)
• Alpha carrier rate: ?
• Beta thal carrier rate: ?
• E-thal carrier rate: ?
• S-thal carrier rate: ??

8. EPIDEMIOLOGY (TCP/ Ba-Tha Registry)
Ba Tha
TOTAL = 706
• Alpha carrier/ trait:
p 263
• Hemoglobin H disease: 16
• Beta thal major: 39
• Beta thal minor: 348
• HbE/ Beta Thal: 39
• Hemoglobin E: 1
• Sickle cell anemia: none

9. EPIDEMIOLOGY (TCP/ Ba-THa Registry)
Ba THa
TOTAL 706
Alpha carrier/trait 263
Hemoglobin H disease 16
Beta Thalassemia Major 39
Beta Thalassemia Minor 348
Beta Thal – E interacting 39
Hemoglobin E 1
Sickle Cell Anemia none

10. EPIDEMIOLOGY (TCP/ Ba-Tha Registry)
Ba Tha
TOTAL 706 1,506
1 506
Extrapolate:
(taking into account the
parents of the index
case)
Alpha
Al h carrier/trait
i /t it 263 263 + 263 = 526
Hemoglobin H disease 16 16 + 32 = 48
Beta Thalassemia Major 39 39 +78 =117
Beta Thalassemia Minor 348 348 + 348 =696
Beta Thal – E interacting 39 39 +78 =117
Hemoglobin E 1 1+1 = 2
Sickle Cell Anemia none 0

11. By HPLC (2008 – June 2011)
• Alpha thalassemia - 60
• Hemoglobin H -
H l bi 11
• Beta thalassemia - 167
• Beta thalassemia-E interacting – 10
• Hemoglobin E –
H l bi 4
• Alpha Beta Thal –
p a ea a 4
• 463 Total samples from 2008 to June 3 2011
Institute of Human Genetics , 2011

12. Patient s
Patient’s Registry
• Balikatang Thalassemia
• Thalassemia Center of the Philippines
• PSHBT

13. National Prevention Program
• Local – Balikatang Thalassemia/
pp
Thalassemia Center of the Philippines
- local communities NCR
• R i
Regional l
• National
at o a

14. Diagnostic Services Available
• Population screening – none yet
p g y
• Prenatal diagnosis – none yet
• Antenatal diagnosis – none yet
A t t l di i t
• Genetic counseling – available
g
• Molecular diagnostic facilities – research
level only
• Primary clinic level or hospital ( g
y p (regional or
national)

15. Diagnostic Services Available
• CBC – standardization lacking
• Hemoglobin electrophoresis (5)
– hospital based
– standardization l ki
t d di ti lacking
– Costly (from P3000 – 10,000)/ $71 -$238
• HPLC (1) Institute of Human Genetics
– cost P1 000 / $23
P1,000

16. BLOOD AND BLOOD COMPONENTS
• NATIONAL POLICY ON BLOOD
• NON REMUNERATED
NON-REMUNERATED
• REPLACEMENT
• PAID DONOR (stopped since 1997)

17. BLOOD and BLOOD COMPONENTS
• Philippine Blood Center (PBC)
– 100% volunteer/ non-remunerated
%
• Philippine Red Cross (PRC)
– 100% volunteer/ non-remunerated
l t / t d
• Hospital Blood Banks
p
– Volunteer/ non-remunerated 50-80%
– As replacement donors 20 50%
20-50%

18. BLOOD and BLOOD COMPONENTS
• Volunteer / Non- Remunerated – 44%
• Replacement Donor - 45%
• Both – 11%
Naranjo, L. and Yuson, E., Survey of Transfusion Patterns and
Practices among Thalassemia Patients in the Philippines”,
Thalassemia Center of the Philippines, 2011

19. BLOOD and BLOOD COMPONENTS
• NATIONAL VOLUNTEER BLOOD
SERVICES PROGRAM
– PHILIPPINE BLOOD CENTER (technical
arm)
– PHILIPPINE BLOOD COORDINATING
COUNCIL (educational arm)
– PHILIPPINE RED CROSS (NGO sector)

20. BLOOD and BLOOD COMPONENTS
• National Blood Services Act of 1994
– To promote and encourage voluntary blood
p g y
donation by the citizenry and to instill public
consciousness of the principle that blood
p p
donation is a humanitarian act
– To lay down the legal principle that the
provision of blood for transfusion is a
professional medical service and not a sale of
a commodity

21. BLOOD and BLOOD COMPONENTS
- to mobilize all sectors of the community to
participate in mechanisms for voluntary and non-
profit collection of blood;
- to mandate the Department of Health to establish
and organize a National Blood Transfusion Service
Network in order to rationalize and improve the
provision of adequate and safe supply of blood;

22. BLOOD and BLOOD COMPONENTS
- to provide for adequate assistance to institutions
promoting voluntary blood donation and providing
non-profit blood services, either through a system
of reimbursement for costs from patients who can
afford to pay or donations from governmental and
non-governmental entities;

23. BLOOD and BLOOD COMPONENTS
- to require all blood collection units and blood
banks/centers to operate on a non-profit basis;
- to establish scientific and professional standards
for the operation of blood collection units and
blood banks/centers in the Philippines;

24. BLOOD and BLOOD COMPONENTS
- to regulate ensure the safety of all activities
related to the collection, storage and banking of
blood
- to require upgrading of blood banks/centers to
include preventive services an education to control
spread of blood transfusion transmissible
diseases.

25. BLOOD AND BLOOD COMPONENTS
• PERCENTAGE DONATED TO
THALASSEMICS – approx 2 – 5%
pp
• BLOOD TRANSFUSION – screening and
processing fee P 1 100 00 ($ 26 19)
1,100.00 26.19)
• HOW OFTEN ARE PATIENTS WITH
THALASSEMIA TRANSFUSED – 3 – 12
wks

26. BLOOD AND BLOOD COMPONENTS
• Pre-transfusion hemoglobin: 8.1- 9 gms
(23%)
• Post transfusion hemoglobin: 10 – 10.9g
(33%)
Naranjo, L. and Yuson, E., “ Survey of Transfusion Patterns and
Practices among Thalassemia Patients in the Philippines ,
Philippines”,
Thalassemia Center of the Philippines, 2011

27. IRON CHELATION
• ALL 3 CHELATORS ARE AVAILABLE
AND REGISTERED
• IRON CHELATORS ARE EXPENSIVE
• PURCHASED BY PERSONAL FUNDS
• DFO
• DEFERIPRONE
O
• EXJADE
• DFO+ DEFERIPRONE

28. MULTIDISCIPLINARY TEAMS FOR
CARDIAC AND ENDOCRINE PROBLEMS
• Centers with Thalassemia Units – multi-
specialty clinics to handle the
p y
multidisciplinary approach to patients
• No National Policy or Program on this yet

29. AVAILABILITY OF MRI FACILITIES
• MRI available
• T2* TECHNOLOGY - none
T2

30. REFERENCE EXPERT CENTERS
• Thalassemia Center of the Philippines
(
(TCP), since 1995
),
• Balikatang Thalassemia Foundation
(Ba-Tha), since 1993
• Other tertiary hospitals with in-house
Hematology Units / Hematologists, others
gy g ,
established their own Thalassemia centers