Tuberculosis in Indonesia:

Tipping the balance towards better

control

Bachti Alisjahbana

Medical Faculty, Padjadjaran University, TB Operational Research Group, National TB Program, Indonesia

Overview

TB Situation

Program challenges

Operational research

Biomedical research

Conclusion

Indonesia Pop = 247 million

22 High Burden Countries, 2012

Indonesia 5.8%

South Africa 4.9%

China 14.3%

India 21.1%

Other 15.9%

Bangladesh 3.8%

Nigeria 4.9%

Ethiopia 3.3%

Pakistan 3.2%

Philippines 2.7%

In Indonesia : Prevalence: 730.000 (297/100 thousand) Incidence: 460.000 (185/100 thousand) Mortality: 67.000 HIV in TB = ~3% WHO report 2013

91

81

5458

73.8

87 86 86.1 86.789.5 91 91 91 91 91.2

86.7

1.44.6

7.512

19 20 21

30.6

37.6

54

68

75.7

69.872.8 73.1

78.3

60.7

0

10

20

30

40

50

60

70

80

90

100

Tahun

CDR & Success Rate Kasus TB Paru BTA Positif, Indonesia 1995-2011*)

SR CDR

Target CDRI ndo 75%, Global 70%

Target SR Indo 86%, Global ≥ 85% s/d 3rd Quarter (data gathered by 10 Jan 2012)

National TB Program Achievement (WHO, 2013)

Number of TB cases in Bandung municipal year 2012 (population of ~ 2,4 million)

No Institution All

TB suspect All TB

cases (P & EP) PTB

AFB +

1 Hosp. Rotinsulu 1043 221

2 Hosp. BBKPM 427 143

3 Hosp. Imanuel 708 129

4 Hosp. RSHS 1038 115

5 PHC Garuda 255 154 69

6 PHC Pasirkaliki 403 127 55

7 PHC Kopo 316 97 52

8 PHC Cibutu 226 79 42

PHC: Public Health Center; P:pulmonary; EP:Extra pulmonary; AFB: Acid Fast Bacilli

Overview

TB situation

Program challenges

Operational research

Biomedical research

Conclusion

TB Laboratories

3 national

Surabaya

Bandung

Univ Indo, Jakarta

2 referral lab. just passed QA.

5.566 TB lab.

59% (3.284) EQAS,

75% good result

TB-MDR

Among new patients,

resistance to any drug 17.1%

MDR-TB 1.8%.

Retreatment cases,

Resistance 34.3% and

MDT 17.1%.

WHO estimated 6900 cases are MDR TB (annual incidence).

Total notification MDR-TB was 428, (0.12% coverage).

TB-HIV

HIV prevalence in new TB is 3.3%.

~ 1% TB patients

know their HIV status.

Among HIV positive,

only 29% enrolled on

ART.

National Strategy 2016 Toward a free-TB, healthy, just and self- reliant society

Technical Strategies

1.Scaling-up and improve quality DOTS

2.Addressing TB/HIV, MDR-TB, & the needs of poor and vulnerable

3.Engaging all public and private

providers in implementation of ISTC.

4.Empowering TB patients &

communities

National Strategy 2010-2016

Functional Strategies

1.Strengthening health system, HRD and TB control program management

2.Increasing commitment of central and local government

3.Enhancing research, development and

utilization of strategic information

Overview

TB Situation

Program challenges

Operational research

Biomedical research

Conclusion

TB Operational Research Group (TORG)

Under the NTP

Facilitate operational research (OR)

Increase capacity to conduct OR through intensive courses

Review TB research proposals submitted to NTP

Provide technical assistance in OR at National level.

Facilitate implementation of OR results in program

Operational Research Topics

Case detection Com empowerment 5

Hospital (manamgent, ISTC) 3

Laboratory 4

Public health center management 4

Utilization of Remote health post 3

Patient Health seeking behavior 2

Active case findings 1

Private practice 1

Case holding Patient behavior assessment 2

Education, group support, Info tech support 3

Hospital DOTS Management, ISTC 2

MDR TB Factors to increased coverage 1

TB HIV Management of collbaorative 1

Pediatric TB Diagnosis 1

33

Scope of the TORG Network

Evaluation of implementation of Xpert-Mtb-Rif

National level OR

5 Xpert deployed in 2012, 10 more in 2013

Aiming for HIV and MDR-TB

Increase D/ yield,

faster detection MDR TB

Hesitation rely only xpert

Culture still needed

TB prevalence survey

TB prevalence survey Preliminary findings

Smear-positive TB prevalence higher than previously estimated*

Probably more sensitive screening, & diagnosis

Prevalence in rural > urban

Prevalence peaked in 25-34 age. Ongoing significant transmission?

Gaps between prevalence and notifications are greater in men and oldest age

Overview

TB Situation

Program challenges

Operational research

Biomedical research

Conclusion

Biomedical research

New findings

→ new challenges

First project (2000-2005)

Immunogenetic basis of susceptibility to and disease manifestations from tuberculosis

Why patient gets TB

What immunogenetic pattern?

Others condition?

900 Cases, 1000 Control

Funded by KNAW

Setting

Double Trouble... TB & DM

Alisjahbana et al, Int Journ of Tub and Lung Dise, 2006, 10(6), 696-700

age (years)

Control subjects

10

15

20

25

30

35

40

10 20 30 40 50 60 70

Tuberculosis patients

age (years)

Bo

dy m

ass

ind

ex (

kg

/m2

)

10

15

20

25

30

35

40

10 20 30 40 50 60 70

No DM

DM

Bo

dy m

ass

ind

ex (

kg

/m2

)

Africa DM: 11 million (6%) TB: 2.9 million (32%)

Europe DM: 24 million (14%) TB: 0.2 million (2%)

Asia DM: 102 million (60%) TB: 5.6 million (62%)

Oceania DM: 1 million (1%) TB: 0.02 million (0.2%)

South America DM: 10 million (6%) TB: 0.3 million (3%)

North America DM: 23 million (13%) TB: 0.1 million (1%)

Double trouble of TB & DM in Asia

EC, Fp7

To determine

prevalence of DM among TB patients & vice versa

feasible, accurate and cost-effective ways of screening.

DM management level required with TB treatment

glucose control effect on TB treatment outcome

Pathopysiological studies

Pharmacokinetic studies

Rifampicin plasma concentration is significanty reduced in TB-DM patient Nijland et al, 2006, CID

TB Diagnostic

(Lidya Chaidir et al, 2013)

Bacterological studies Drug Sensitivity Testing?

Figure 3. AMK = Amikacin, INH =

Isoniazid, RIF=Rifampicin, PAS=Para

aminosalisilic acid, ETB=Ethambutol,

STR=Streptomicin. Numbers shows

antibiotic concentration in medium

(mg/l).

Con-

trol

1/100 Con-trol

AMK

5

INH

0.1

INH

0.2

INH

0.5

INH

1

INH

2

RIF

0.1

RIF

0.2

RIF

0.5

RIF

1

RIF

2

RIF

5

PAS

1

ETB

1

ETB

2

ETB

5

ETB

10

ETB

20

STR

1

STR

2

STR

5

STR

10

STR

20

The proportional method Multiwell method

TB Beijing genotype

Related with higher disease severity?

Our studies

More severe

More treatment failure

R. Van Crevel, EID, 880 Vol. 7, No. 5, September-October 2001

Population Structure of M. tuberculosis in Papua vs Java

Mtb Finger Printing, show huge variability across Indonesian Islands MIRU-VNTR and MLPA later shows more distinctive power (Lidya Chaidir et al, 2013)

Latent TB IGRA vs Mantoux in children case contact

Latent TB Treatment

Multicenter clinical trial (2012-now)

latent TB (TST +)

800 adult, 300

child

4Rif vs 9INH

safety & efficacy

immunological pattern

Conclusion

Problems

Host Diabetes Immuno-genetic HIV-TB

Operational Research Diagnostic Imuno-diagnostic

Clin evaluation Pharmaco kinetics

Bacteriology Beijing study Drug susceptibility test Transmission dynamic

MDR-TB

Diagnosis & Management

Coevolution study

Thank You

TB Operational Research Group

TB research Group Bandung

5 Level of TB Laboratory

1.Satellite facility

2.Health facility lab. TB microscopy.

3.Intermediate TB laboratory located in District. Cross check service level I

4.Province referral TB laboratory providing

cross check for level 2

5.National referral TB laboratory.