SMART PARTNERSHIP IN

DETECTING SPUTUM SMEAR

POSITIVE TUBERCULOSIS (TB) :

AN EXPERIENCE IN THE

DISTRICT OF BATU PAHAT

Linayanti R1, Arbaiah O1, Rashidah D1,

Mohd Asri Z1, Naimah I1, Noorhaida U2

1 Batu Pahat Health Office

2 Muar Health Office

INTRODUCTION

• Detection rate of smear positive Tuberculosis in Batu Pahat Johor, remains less than 70% over the last 5 years.

• The management feels that more aggressive approach must be introduced to the current situation.

• Involvement of the private practitioner plays an important role in TB detection and its management.

BATU PAHAT DISTRICT

3

Area: 1872.56 Km2

Population : 406 400

(2011)

Health Clinic: 15

District Hospital: 1

Private Hospital: 2

Private Clinic : 70

Chest Clinic (PR 1)

located in Batu Pahat

Health Clinic ,

Jln Kluang

Trend of TB in Johor, 1990 - 2011

626

625

622

660

759

704 851

984

1009 1158

1215 1

366

1311 1422

1443

1407 1

553

1591

1700 1

854

2058

2038

30

29

29

29

33

29

34

39

39

43

44

50

45 4

8

48

45

49

49

54

53

61

61

22

22

21

19 2

2

19 21

25

24

28

27

29

24

25 26

26

28

27

29

27

30

29

0

10

20

30

40

50

60

70

0

500

1000

1500

2000

2500

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

No. of cases Incidence Rate Incidence rate (Sputum Positive)

Case Detection Rate by district, Johor, 2010-2011

69

44

51

62

66

38

54

80

57

43

60

70

55

50 51

64

40

52 55

36

52 55

0

10

20

30

40

50

60

70

80

90

JB MUAR BP KLUANG KT SEGAMAT PONTIAN MERSING KJ LEDANG JOHOR

CD

R %

District

2010 2011

OBJECTIVES

• General:

To increase the detection rate of smear positive TB in

Batu Pahat

Specifics:

• To increase detection rate of sputum smear

positive TB to 70%

• To improve the quality of sputum taken

• To increase sputum AFB screening of the new

outpatient cases to 2%

• To improve knowledge and awareness among

health staffs and community

METHODOLOGY

• A cross sectional study using self administered

questionnaire for health staff and community to

determine the knowledge and awareness of

Tuberculosis.

• 44 staffs and 100 individuals were recruited in the study

via random sampling.

• Retrospective review on sputum AFB data to analyze the

quality of the specimen.

• A cross sectional study among patients referred for

sputum AFB in Klinik Kesihatan Batu Pahat

METHODOLOGY

• The data were analyzed using SPSS version 15.0.

• Action research framework was applied to overcome the

problem by engaging the entire stakeholder involved in

TB management including private practitioners.

PLAN

REFLECT

ACT AR Cycle

METHODOLOGY

Group discussion

Stakeholder meeting Proposal presentation to the

stakeholders (10.8.11)

Addition to objectives and list of

activities.

Overall positive feedbacks from all

stakeholders.

AR group discussion (19.8.11)

• Brainstorming

• Reviewing secondary data and

literature review

• Survey questionnairre

Major Problems Identified

1. Low notification because of

low awareness among staff

and GP

2. Low Sputum Quality

because of lack of

knowledge among staff and patients

3. Low screening because of

lack of knowledge

and awareness

METHODOLOGY

Actions to overcome the problem:

Increasing the knowledge and awareness

TB alert card

Development of new health promotion materials

Infoblast

Workshops/trainings

Continuous Medical Education (CME)

Monitoring of adherence to standard procedure of

TB management

Implement three clinic days per week.

RESULTS AND

DISCUSSION

- 62.2% referred by

MO

- 66.7% was referred

for cough more than

7 days

- 15 (4.7%) smear

positive were

detected

Cross sectional study among patients referred for

sputum AFB in Klinik Kesihatan Batu Pahat , 2011

(n=320)

Knowledge and awareness of TB among

community (n=100)

58% have good knowledge on TB

The younger age group (<30 years old) have good

knowledge compared to others

Women have better knowledge compared to man

Most common source of TB information was from

newspaper, magazines and television

55% agreed that TB is a serious problem

97% knows that anybody can be infected by TB

55% do not know how TB can be cured

13% afraid of TB patient, 58% felt sorry for them

95% would like to know more about TB

Knowledge and awareness of TB among Health Staff

(n=44)

• 34.4% never attended TB course

• 47.7% never had no experience managing TB patient

• 47.7% unable to recognize TB

• 79.5% answered wrongly for the treatment of TB

• 84.1% did not know when to refer TB cases

• 75.5% did not know definition of DOTS

• 64.1% did not know the correct monitoring of TB patients

• 84.1% did not know how to prevent TB among healthcare worker

TB workshop

(2.11.11)

Monthly

CME /

Epid

Review

Workshops and CME to Health staff and

Private Practitioner

Health education:

Cough Technique

New bunting for every Health Clinic

TB buntings inside the clinics

Cough technique posters

in every treatment room

and cough corner

2nd Jan 2012

Reshuffling of

Chest Clinic Staff

Dr. Zaleha Jailani, SN Nurul

Aida, JM Azira

• Before • After

DAY CLINIC

AKTIVITY

MONDAY CONTACT

SCREENING

TUESDAY CONTACT

SCREENING

WEDNESDAY CHEST CLINIC

THURSDAY CONTACT

SCREENING

FRIDAY CHEST CLINIC

Change of clinic schedule

DAY CLINIC

AKTIVITY

MONDAY CONTACT

SCREENING

TUESDAY CHEST CLINIC

WEDNESDAY CHEST CLINIC

THURSDAY CHEST CLINIC

FRIDAY CONTACT

SCREENING

PPP U29

d/a Klinik Kesihatan Rengit

Tuan,

PERINGATAN : PERTAMA

LAPORAN PENCARIAN KES JANUARI 2012

Adalah saya dengan hormatnya merujuk kepada

perkara di atas.

Dukacitanya dimaklumkan bahawa Laporan

Pengesanan Awal Kes yang dijalankan oleh pihak

tuan melalui Klinik Kesihatan dari Bulan Januari

berdasarkan reten Jumlah Saringan AFB adalah

1.1% berbanding jumlah sasaran yang ditetapkan

iaitu 2% .

Sehubungan dengan itu, pihak tuan diarahkan

untuk meningkatkan pencapaian di Klinik Kesihatan

masing-masing. Surat peringatan Kali Kedua

akan menyusul beserta surat tunjuk sebab

sekiranya pencapaian yang telah ditetapkan masih

tiada perubahan.

Kerjasama dan keprihatinan pihak tuan di dalam

perkara ini amat dihargai.

Sekian, terima kasih.

Reminder letter

Percentage of TB cases, Batu Pahat Johor 2008 - 2012

55.1 64.5

54 50 57.7

33.3 23.5

36 35.2

32

11.6 12 10 14.8 10.3

0

10

20

30

40

50

60

70

80

90

100

2008 2009 2010 2011 2012(Jan-April)

Pe

rce

nta

ge

of T

B c

ase

s

Smear positive Smear negative Extrapulmonary

Incidence rate of TB, Batu Pahat Johor,

Jan- April 2008 - 2012

7.4

6.05

7.2

9.3

11.07

0

2

4

6

8

10

12

2008 2009 2010 2011 2012

Incid

en

ce /100 0

00 p

op

ula

tio

n

Year

14.8

12.1

14.4

18.6

22.2

0

5

10

15

20

25

2008 2009 2010 2011 2012

CD

R (

%)

Year

Case detection rate, Batu Pahat Johor,

Jan – April ,2008 - 2012

Results

• CDR:

– Detection rate of smear positive Tuberculosis was

22.2% as compared to 18.6% during the same period

in 2011.

• Unsatisfactory sputum specimens:

– Reduced from 39.3% (2011) to 34.5% (2012)

Source of notification for TB cases, Batu Pahat Johor,

2008 - 2012

38.4 41.5 40.5 32.2

25.6

42 44

40 46.6

48.8

19.6 14.5 19.5 21.2 25.6

0

10

20

30

40

50

60

70

80

90

100

2008 2009 2010 2011 2012 (Jan-

April)

Perc

en

tag

e

Year Health Clinic Hospital Private

Percentage of sputum AFB screening of the new outpatient

cases in health clinic, Batu Pahat, 2007 – 2012 (Jan - April)

2.23

1.7 1.9

2.3

2.04 2.06

0

0.5

1

1.5

2

2.5

2007 2008 2009 2010 2011 2012

Perc

en

t of

patien

t scre

en

ed

Year

Detection of new TB cases from GP alert card

Year No. of cases

referred

No. of confirmed

cases

2011 71 1 (1.4%)

2012

(Jan-April)

15 2 (13.3%)

Level of Knowledge on TB management among health

staff, Batu Pahat, 2012

4.5

43.2

52.3

40.9

50

0 0

10

20

30

40

50

60

Good Satisfactory Poor

Pe

rce

nta

ge

of

sta

ff

Level of knowledge

Pre intervention Post intervention

CONCLUSION

• Participatory action of all members of

stakeholders in Action Research methodology is

a good approach to overcome problem of low

detection rate of smear positive Tuberculosis in

Batu Pahat District.

• Detection rate increased to 22.2% from 18.6%

REFERENCES

• Ministry of Health Malaysia, 2002, Practice Guideline for the Control and

Management of Tuberculosis

• Ministry of Health Malaysia, 2002, National Tuberculosis Information System – TBIS Manual

• Noriah B et al, 2010, Action Research: Trainer’s Guide

• Batu Pahat Health Office, 2010, Annual Report

• Batu Pahat Health Office, 2011, Annual Report

• World Health Organization, 2011, Global Tuberculosis Control

• Aziah A.M, 2004, Tuberculosis in Malaysia: Combating the Old Nemesis,

Medical Journal Malaysia 59 : 1-3

THANK YOU….

TOGETHER WE STOP TB

Number of TB cases in Batu Pahat Johor , 2003 - 2012

86 76

106 109 118

45 39

46 41

72

83

25

11 16 19 19

35

8

136 138

166

200

236

78

0

50

100

150

200

250

2007 2008 2009 2010 2011 2012 (Jan - April)

Nu

mb

er

of

TB

ca

se

s

Year

Smear positive Smear negative Extrapulmonary All TB cases

Incidence of TB, Batu Pahat, 2008 - 2012

0

10

20

30

40

50

60

2008 2009 2010 2011 2012(Jan-April)

Inc

ide

nc

e /1

00

00

0 p

op

ula

tio

n

Smear positive Smear Negative Extrapulmonary All cases

37.61 40.1 41.25

56.2

22.15

0

10

20

30

40

50

60

70

80

90

100

2008 2009 2010 2011 2012(Jan-April)

CD

R (

%)

Year

Case detection rate, Batu Pahat Johor, 2008 - 2012

Target > 70%