Syntax Literate: Jurnal Ilmiah Indonesia p–ISSN: 2541-0849 e-ISSN:
2548-1398
Vol. 9, No. 10, Oktober 2024
ANALYSIS OF TUBERCULOSIS CONTROL (CASE STUDY IN THE CITY OF MOJOKERTO) YEAR 2024
Mokhamad Suyono Yahya1,
Bambang
Setiaji2
Universitas Indonesia Maju, Jakarta, Indonesia1,2
Email: [email protected]1
Abstract
This study aims to analyze the tuberculosis (TB) situation in Mojokerto
City, focusing on the increase in cases among children and identifying
effective countermeasures. TB, a preventable and curable infectious disease
caused by Mycobacterium tuberculosis, is particularly problematic in developing
countries like Indonesia due to high incidence and mortality rates,
necessitating a comprehensive control strategy. Employing qualitative methods,
this research delves into the practices, perceptions, and social dynamics
affecting TB control efforts in Mojokerto, illuminated by the latest data
showing a significant increase in pediatric TB cases and the public health
situation. Findings reveal a TB incidence rate of 385 per 100,000 inhabitants,
a case detection rate of 75%, and a notably high pediatric TB case proportion
of 32%. The effectiveness of case tracking by health centers varies, with an
average of only 54% receiving Tuberculosis Preventive Therapy (TPT). Major
obstacles include limited access to radiology services, social stigma, and the
need for adequate health facilities. Innovations such as the "Mbak Desi
Fights TB" program and enhanced cross-sector cooperation are deemed
crucial to strengthen control strategies. The study concludes that a
multifaceted strategy is essential for combating TB in Mojokerto, which should
include enhanced case detection, health system strengthening, and community
integration in control efforts. Increased collaboration across sectors and
advancements in research and development are expected to accelerate TB
elimination. This research offers efficient recommendations to improve TB
control strategies, based on an in-depth analysis of the current conditions and
social dynamics in Mojokerto.
Keywords: Tuberculosis, Mojokerto City, case detection,
Tuberculosis Preventive Therapy (TPT), social stigma, sector collaboration, TB
research.
Introduction
Tuberculosis (TB) is a
disease caused by the bacterium Mycobacterium tuberculosis, which most commonly
affects the lungs
In Indonesia, the TB
situation is also concerning. The country ranks third after India and China in
the number of TB cases
In East Java, from
January to October 2022, the region ranked eighth for treatment coverage at
49.56% compared to the national rate of 49.43%, including about 4,408 cases of
pediatric TB (55.43%), 74% of TB RO cases starting second-line treatment, 1,245
cases (3.7%) with TB-HIV burden, a treatment success rate of 82.79%, and a
55.51% treatment success rate for TB RO, resulting in 1,660 deaths (5.04%).
The situation in
Mojokerto City, despite achieving 100% of the minimum service standards for TB
(Implementation of Minimum Service Standards for Tuberculosis) with 688 cases
found and treated out of a target of 600 cases, this paper will specifically
focus on the discovery of TB patients in Mojokerto City area because there
appears to be a significant problem: in Mojokerto City itself, there is a
significant increase in pediatric TB cases where in total there is an increase
of 103% (from 84 to 171 cases), including nine times more in Gunung Gedangan
Village (from 1 to 9 cases), seven times more in Kedundung Village (from 4 to 7
pediatric TB cases), and five times more in Magersari Village (from 2 to 11
cases). The proportion of pediatric TB cases compared to all cases in 2021 was
31.3% and in 2022 it was 25.9%, which is above the target of only 5%,
indicating that there are still sources of transmission that need to be
identified and treated to break the chain of transmission.
The Indonesian
government has issued policies to strengthen TB control, including Presidential
Regulation No. 67 of 2021 on TB, the Minister of Health Regulation No. 67 of
2016 on TB control, the Minister of Health Regulation No. 4 of 2019 on
technical standards for fulfilling Basic Service Quality in Minimum Service
Standards (SPM) for health, and the Governor Regulation No. 50 of 2022 on TB
control.
The author aims to
explore the implementation of tuberculosis control in Mojokerto City through a
qualitative approach. The purpose of this study is to obtain an in-depth
overview of practices, perceptions, and social dynamics that influence TB
control efforts. It is hoped that the results of this study can provide
efficient recommendations and valuable inputs to improve tuberculosis control
strategies in the city
Research Methods
The research design is qualitative
1) The Head of the Mojokerto City Health and Family
Planning Office
2) The Head of Disease Prevention and Control Division
3) The Sub-coordinator of Disease and Vector Control
4) The Sub-coordinator of Health Promotion
5) The Village Head of Magersari
6) The Village Head of Gunung Gedangan
7) TB Program Manager at Gedongan Health Center
8) TB volunteers at Gedongan and Kedundung Health Centers
9) Active TB patients at Gedongan and Kedundung Health
Centers
10) The Head of the Mojokerto City Zakat Administration
Body
11) The East Java Provincial Health Office Representative
The variables under study include TB control
strategies referenced in Presidential Regulation No. 67 of 2021, which
addresses the following strategies:
1) Strengthening Commitment and Leadership at the
Central, Provincial, and City Government levels
2) Enhancing the Quality and Patient-Centered Access to
TB Services
3) Intensifying Health Efforts for TB Control
4) Enhancing Research, Development, and Innovation in TB
Control
5) Increasing Community Involvement, Stakeholder
Engagement, and Multi-sectoral Collaboration in TB Control
6) Strengthening Program Management
After collecting interview data, transcription and
coding will be conducted to determine whether the above strategies have been
implemented, are still in process, or are facing obstacles, through a matrix
Data analysis will combine findings from both
secondary data and in-depth interviews referring to the strategies outlined in
Presidential Regulation No. 67 of 2021 to see if they have been executed, are
in process, or are facing obstacles, and then interpreted by the researcher
This research has received ethical approval from the
Universitas Indonesia Maju Indonesia, with approval number
701/SPm/DKN/FIKes/UIMA/II/2024.
Results and Discussion
Table 1. TB Case Tracking and Preventive Therapy Administration in Mojokerto
City, 2023
|
Puskesmas |
Total Population |
Total TB Cases |
Pediatric TB Cases |
Estimated |
Case Detection Rate |
Percentage of Pediatric TB |
Contact Investigation Conducted for Symptomatic TB |
TB Disease |
Number of Contact Investigations for Asymptomatic Individuals |
Percentage of Contact Investigations |
Contacts Given TPT per Contact Investigation |
% Total |
|||
|
|
|
|
|
|
|
|
(< 5 yo) |
(>= 5 yo) |
total |
|
|
90 |
(< 5 yo) |
(>= 5 yo) |
|
|
Puskesmas Wates |
19305 |
46 |
10 |
74 |
62 |
22 |
1 |
38 |
39 |
39 |
85 |
19 |
46 |
49 |
|
|
Puskesmas Kedundung |
22475 |
71 |
24 |
87 |
82 |
34 |
4 |
60 |
64 |
64 |
90 |
40 |
62 |
63 |
|
|
Puskesmas Gedongan |
21392 |
77 |
22 |
82 |
94 |
29 |
2 |
38 |
40 |
2 |
38 |
49 |
23 |
58 |
61 |
|
Puskesmas Blooto |
23217 |
65 |
19 |
73 |
46 |
26 |
2 |
50 |
52 |
50 |
77 |
20 |
33 |
40 |
|
|
Puskesmas Mentikan |
25197 |
80 |
23 |
97 |
82 |
28 |
4 |
57 |
61 |
1 |
64 |
80 |
37 |
55 |
58 |
|
Puskesmas Kranggan |
21257 |
46 |
16 |
82 |
56 |
34 |
4 |
60 |
64 |
11 |
24 |
5 |
42 |
45 |
|
|
Total |
132843 |
385 |
125 |
511 |
449 |
32 |
26 |
243 |
269 |
3 |
266 |
69 |
144 |
34 |
54 |
Source: System Information
Tuberculosis 2023
From Table 1 above, it can be noted that only
69% of TB patients underwent case tracking, with the highest percentage at the
Kedundung Health Center (90%), followed by the Wates Health Center (85%) and
the Mentikan Health Center (80%). Meanwhile, Health Centers that conducted case
tracking below 50% are the Gedongan Health Center (49%) and the Kranggan Health
Center (24%). Subsequently, after tracking, only 54% received Tuberculosis
Preventive Therapy.
According to the
interview with informants, there is an obstacle for X-ray examinations, which
is that the execution of X-rays can only be performed at hospitals with a
referral
Figure 1. The flow of Latent Tuberculosis
Infection (LTBI) examination for household contacts of TB SO/RO patients
according to the Circular of the Director General of Disease Prevention and
Control No.: HK. 02.02/C/2175/2023 regarding the changes in the implementation
of contact investigation and the examination flow of Latent Tuberculosis
Infection (LTBI) and the administration of Tuberculosis Preventive Therapy
(TPT) in Indonesia
Referring to Figure 1 above, it can be noted that close contacts aged ≥ 5 years who are
asymptomatic should undergo thoracic X-ray examinations. However, currently at
the Health and Family Planning Office, access to thoracic X-rays is only
available at hospitals, and there is no mobile X-ray facility available yet.
Table 2. Access to Healthy Housing per Neighborhood in Mojokerto City, 2023
|
No |
Subdistrict |
Village |
Health Center/ Puskesmas |
Total Households |
Household Air Quality Management (Number) |
Household Air Quality Management (%) |
Healthy Household Access (Number) |
Healthy Household Access (%) |
|
1 |
Magersari |
Wates |
Wates |
6830 |
5316 |
77.83 |
4479 |
66 |
|
2 |
Magersari |
Gunung Gedanga |
Kedundung |
2700 |
2510 |
92.96 |
2510 |
92.96 |
|
3 |
Magersari |
Kedundung |
Kedundung |
5367 |
4336 |
80.78 |
4336 |
80.78 |
|
4 |
Magersari |
Balongsari |
Gedongan |
2733 |
2324 |
85.03.00 |
2105 |
77 |
|
5 |
Magersari |
Gedongan |
Gedongan |
816 |
672 |
82.35.00 |
680 |
83.27.00 |
|
6 |
Magersari |
Magersari |
Gedongan |
2000 |
1818 |
90.88 |
1818 |
90.88 |
|
7 |
Magersari |
Purwotengah |
Gedongan |
580 |
494 |
85.22.00 |
494 |
85.23.00 |
|
8 |
Kranggan |
Sentanan |
Gedongan |
737 |
566 |
71.89 |
566 |
71.89 |
|
9 |
Kranggan |
Jagalan |
Gedongan |
1009 |
865 |
85.75 |
865 |
85.75 |
|
10 |
Kranggan |
Kranggan |
Kranggan |
4594 |
3549 |
77.25.00 |
3549 |
77.25.00 |
|
11 |
Kranggan |
Meri |
Kranggan |
3017 |
2562 |
84.09.00 |
2562 |
84.91 |
|
12 |
Kranggan |
Miji |
Mentikan |
2957 |
2425 |
82.02.00 |
2425 |
82.02.00 |
|
13 |
Prajuritkulon |
Mentikan |
Mentikan |
2248 |
1785 |
79.03.00 |
1785 |
79.39.00 |
|
14 |
Prajuritkulon |
Kauman |
Mentikan |
1075 |
672 |
62.05.00 |
650 |
60.41.00 |
|
15 |
Prajuritkulon |
Pulorejo |
Kranggan |
2878 |
2392 |
83.11.00 |
2392 |
83.11.00 |
|
16 |
Prajuritkulon |
Surodinawan |
Blooto |
2983 |
2680 |
89.85 |
2983 |
100 |
|
17 |
Prajuritkulon |
Prajuritkulon |
Blooto |
2733 |
2677 |
97.93 |
2677 |
97.93 |
|
18 |
Prajuritkulon |
Blooto |
Blooto |
2390 |
2170 |
90.79 |
1946 |
81.41.00 |
|
Total |
47697 |
39814 |
83.47.00 |
38821 |
81.39.00 |
Source: 2023 Health Profile of Mojokerto City
From Table 2 above, it can be observed that the
access to Healthy Housing in Mojokerto City is 81.39%. For the Gunung Gedangan
neighborhood, access to Healthy Housing is 92%, in Kedundung it is 80%, and in
Magersari it is 90%. For neighborhoods with access below 80%, the proportion of
pediatric TB cases is also greater than 5%. The research results also indicate
a strong positive correlation between the coverage of healthy housing and the
discovery of tuberculosis cases (p = 0.01 < 0.05; r = 0.68).(3) the results of the assessment of TB control
strategy implementation in Mojokerto City, based on Presidential Regulation No.
67 of 2021, can be described as follows:
Strategy 1:
Strengthening the Commitment and Leadership of Central, Provincial, and
Municipal Governments
Outcome: Implementation
of annual coordination meetings attended by stakeholders.
Enhancing TB control
efforts indeed requires intensification and a more specific focus on this topic
Once this team is
established, significant progress is anticipated across various aspects. These
include the execution of more organized TB elimination campaigns, which not
only raise awareness but also mitigate the social and workplace stigma
associated with TB. Moreover, the team will focus on improving the quality of
life for TB patients through the provision of healthy housing and improved
nutritional intake, which are critical factors in recovery and prevention of TB
spread.
Cross-sector
involvement will also be key in these efforts, given that TB control requires
more than just health sector interventions but also support from various
entities, including local governments, community organizations, the private
sector, and the general public
Strategy 2: Enhancing
Access to Quality, Patient-Centered TB Services
Outcome: Availability
of sensitive and specific diagnostic facilities for TB accessible to the entire
population.
Challenges in accessing
Radiology or X-ray services, particularly for individuals over 5 years old,
represent a significant barrier to enhancing TB case detection. Radiology
facilities for TB screening can impede the process of rapid and accurate
diagnosis, which is crucial for TB management.
The use of mobile
radiology facilities could be an effective solution to address this issue. With
greater mobility, these facilities can bring radiology services closer to those
in need. This will expedite the TB screening and diagnosis process, particularly
for individuals over 5 years old, thus allowing for quicker diagnostic
confirmation.
The presence of mobile
radiology facilities not only enhances TB case detection coverage but also
plays a crucial role in the overall TB elimination strategy. It allows for more
rapid and accurate interventions, reduces the risk of further transmission, and
ensures that treatment can begin as soon as possible. To realize this, support
from various stakeholders, including the government, health organizations, and
the community, is vital for the provisioning and operation of mobile radiology
facilities.
Outcome for
Infrastructure Enhancement: Increased capacity of service facilities
(strengthening infrastructure development, laboratories, and TB RO service
expansion). A network has already been established between clinics and private
practice doctors in Mojokerto for the detection and treatment of TB patients,
and in 2024, the Mojokerto City Health and Family Planning Office is preparing
healthcare facilities for Drug-Resistant TB, to be managed by Dr. Wahidin
Sudiro Husodo Hospital in Mojokerto.
Strategy 3: Intensification of Health Efforts for Tuberculosis
Control
Output: Implementation of activities for intensification and
integration of TB patient discovery at every Health Service Facility.
Although TB-DM (Diabetes Mellitus) and TB-HIV programs have been operational, there remains a shortfall in access to training as well as monitoring and evaluation activities for pulmonologists, internists, and pediatricians. Currently, participation in these activities tends to be limited to TB program managers at hospitals. However, several initiatives, such as the KOPI TBC and meetings featuring speakers from the East Java Provincial Health Office and pulmonologists from Mojokerto City, have been organized to address these issues.
Output: The conduct of active,
institution- and community-based patient discovery activities through contact
tracing and mass screening in areas with a high TB burden.
Output: Availability of facilities and access to quality
management and treatment for all types and forms of TB
(pulmonary/extrapulmonary, drug-sensitive/drug-resistant) without
discrimination based on age group and HIV status.
Output: Availability of Tuberculosis Preventive Therapy (TPT)
medications, and the implementation of TPT.
Despite efforts involving clinics, independent doctors, and TB cadres in detecting cases, the process of examining index cases still faces challenges, particularly related to the need for X-ray examinations requiring hospital visits. This constraint is not only associated with distance and time but also the referral process through the BPJS health insurance that requires a complicating case condition. An urgent solution is needed for this issue. To support this, there is a need for wider case tracking, involving various sectors, providing TB preventive therapy, and conducting specific monitoring and evaluation activities to address these issues.
Strategy 4: Enhancing Research, Development, and Innovation in TB
Control
In Mojokerto City, an innovation known as "Mbak Desi Berantas
TBC" (Ms. Desi Fights TB) has been launched. This program involves weekly
disinfectant spraying activities at TB patients' homes to reduce transmission
risks. Uniquely, this activity is run by the community with funding from the
local village funds, showcasing a collaborative approach between local
government and the community in combating TB. This initiative targets not only
the reduction of disease spread but also strengthens community participation in
public health efforts.
Strategy 5: Enhancing the Role of Community, Stakeholders, and
Multisectoral Involvement in TB Control
Output: The number of districts/cities implementing integrated
TB elimination acceleration actions.
TB Elimination Acceleration Actions: This effort is ongoing with the goal to be
implemented in all districts/cities by 2024. This process begins with the
formation of TB elimination acceleration teams and the development of local
action plan documents, which are currently in progress and expected to demonstrate
sustained commitment to integrated TB control.
Strategy 6: Strengthening Program Management
Output: Achievement of all performance and managerial
indicators for TB Control activities for Health Service Facilities and
individual performance indicators for health cadres.
Output: Achievement of the expected contribution criteria in
reaching the TB Control targets at the national and local levels.
Mojokerto City has demonstrated impressive achievements in TB control, receiving awards at the East Java Province level for the past three years. This reflects the dedication and collective efforts in combating TB in the city. However, there are areas that still need improvement, particularly in terms of specifically recognizing health service facilities (both government-managed and private), community organizations, and cadres. While Mojokerto City has made significant progress, more specific recognition and appreciation for individuals and entities directly involved in TB management, especially during significant moments like National Health Day, have yet to be fully implemented. This indicates that there are still opportunities to enhance motivation and recognition for all parties directly involved in TB control efforts in Mojokerto City.
From the strategies and outputs presented, several major issues and efforts that need immediate attention in TB control, particularly in Mojokerto City, have been identified:
Expansion of Focus and Intensification of Efforts: While progress has been made, TB-related meetings need to be more focused and specific, pending the formation of the TB Elimination Acceleration Team. This team is expected to strengthen control efforts with more organized campaigns and improved quality of life for patients.
Enhancement of Diagnostic Service Access: Barriers to accessing Radiology/X-ray services, especially for individuals over 5 years old, highlight the need for mobile radiological facilities to expedite the screening and diagnostic process.
Cross-Sector Involvement: TB
elimination strategies require support and cooperation across sectors to
enhance control efforts, including the provision of preventive therapy and
activities for monitoring and evaluation
Innovation and Community Participation: Programs like "Mbak Desi Berantas TBC" illustrate the importance of innovation and community participation in TB control efforts, which require ongoing support.
Recognition and Appreciation for Contributors: Although Mojokerto City has received provincial-level awards, there
is a need for more specific recognition of health service facilities, community
organizations, and cadres contributing to TB management
Strengthening of Program Management: There is a need to strengthen TB program management, including
achieving performance indicators for health service facilities and health
cadres, as well as contributing to national and local TB control targets
Solutions to these issues involve an integrated approach that includes strengthening government commitment, enhancing access to quality services, intensifying health efforts, innovating, and strengthening community participation and program management. Through coordinated efforts across sectors and recognition of all involved parties, TB elimination efforts in Mojokerto City are expected to be more effective and comprehensive.
Discussion
Research and data on
the tuberculosis (TB) situation in Mojokerto City reveal several crucial
findings that necessitate a thorough discussion to identify effective mitigation
steps:
TB Incidence and Case
Detection Rates: The high incidence rate of TB in Mojokerto City indicates a
need for improvement in the case detection rate. Findings about the high
proportion of pediatric TB cases in several neighborhoods underscore the need
for more focused detection and treatment strategies for adult age groups.
Global best practices highlight the importance of robust surveillance systems
and targeted interventions to identify and treat TB cases, especially in
at-risk populations.
Case Tracking Efforts:
The effectiveness of case tracking by health centers varies, signifying the
importance of evaluating and enhancing case tracking capabilities. Effective
implementation of Tuberculosis Preventive Therapy (TPT) is key in prevention efforts.
Challenges related to radiological examinations and their impact on case
detection, as well as social stigma, are major obstacles in TB control efforts.
The World Health Organization (WHO) emphasizes the importance of addressing
these barriers through improved access and community acceptance of TB
treatment.
Access to Healthy
Housing: The correlation between access to healthy housing and TB case
detection emphasizes the importance of good living conditions as part of the TB
control strategy. This aligns with WHO recommendations on infection prevention
and control in high-risk settings.
Implementation and
Effectiveness of TB Control Strategies: An evaluation of TB control strategy
implementation should include strengthening government commitment and improving
access to TB services. The importance of innovation and community involvement,
as demonstrated by the "Mbak Desi Berantas TBC" initiative, indicates
the need for collaborative and innovative approaches in TB control.
Need for Facilities and
Resources: The demand for more sensitive diagnostic facilities and adequate
infrastructure for TB treatment underscores the importance of investing in
health resources. This is consistent with recommendations to enhance healthcare
service capacity in detecting and treating TB.
Recommendations and
Next Steps: Addressing the challenges in TB control in Mojokerto City requires
enhanced cross-sector collaboration and increased research and development. As
outlined in the literature, global and local efforts must be synchronized to
achieve effective control and elimination of TB.
Integrating research
data with best practices and recommendations from reputable sources like the
WHO, this discussion offers insights for formulating comprehensive and
sustainable TB control strategies in Mojokerto City.
Conclusion
The research on the Tuberculosis (TB) situation in Mojokerto City reveals the need for improvement in case detection, especially among children, and the strengthening of surveillance systems and interventions. The variability in the effectiveness of case tracking by health centers, challenges in Tuberculosis Preventive Therapy (TPT), and obstacles such as social stigma and access to radiological examinations indicate the need for evaluation and enhancement of tracking and treatment capacities. The correlation between access to healthy housing and case detection emphasizes the importance of good living conditions in control strategies, in line with WHO guidelines. The implementation and effectiveness of countermeasures highlight the importance of collaborative approaches and innovations, such as the "Mbak Desi Berantas TBC" initiative, as well as increased investment in health facilities and resources. Cross-sectoral synergy and increased research are required to achieve effective and sustainable TB control and elimination in Mojokerto, integrating global best practices with local conditions.
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