Tuberkulosis Anak, DOTS, ISTC

Finny Fitry Yani

Courtesy :
UKK Respirologi Anak IDAI
World problems of Tuberculosis (TB)
Global problem
Neglected Childhood TB
Low Case Detection Rate
Lack of holistic approach of TB management
Non-standardized management



Global burden of tuberculosis (TB)
1/3 of the population of the world have been infected
Prevalence: 17.22 million (1990s ) 11.1 million (2008 )
New cases/year: 9.3 million (2007) 9.4 million (2008)


TUBERCULOSIS PROGRAMS
GOAL:
to break the chain of the transmission for
eliminating the disease from society.

Strategies:
1)case finding and treatment of active disease
2)treatment of LTBI
3)vaccination with BCG
National TB Programs
(NTPs)= P2 TB Kemenkes
Focus on adult cases
Pediatric
TB
DOTS
(Directly Observe Treatment Short-course)
A global strategy to combat world TB problems

Developed by WHO and IUATLD

Introduced in early 1990, implemented in
Indonesia since 1994s
DOTS coverage in 2006: 98%
Komitmen Politis dan dukungan
semua pihak
1
WHO 1991
2
Diagnosis
mikroskopik
ANAK??
3
Pengawas Menelan Obat
4
Ketersediaan Obat
5
Pencatatan Pelaporan

Cure rate tinggi (pemutusan
rantai transmisi)
Paling cost effective (Bank
Dunia)
Rekomendasi WHO
Tujuh Strategi Utama Program Nasional
Penanggulangan TB
Equitable Quality DOTS Expansion Indonesia
Ekspansi Quality DOTS
1. Perluasan & Peningkatan pelayanan DOTS
berkualitas
2. Menghadapi tantangan baru, TB-HIV, MDR-TB dll
3. Melibatkan Seluruh Penyedia Pelayanan
4. Melibatkan Penderita & Masyarakat

Didukung dg Penguatan Sistem kesehatan
5. Penguatan Policy & Kepemilikan Daerah
6. Kontribusi thd Sistem Pelayanan Kesehatan
7. Penelitian Operasional
SEMBUH
TB management in Indonesia
PHCs
Government Private
Private
practices
Private
hospitals
Government
hospitals
Healthcare providers
BP4 RSP
GP Pulm
DOTS
strategy
HOSPITAL DOTS LINKAGE
(HDL)
TB IN HOSPITALS
Case finding : high
(DIY: hospital 36%; PHCs 27%; BP4 37%)
Have no working area
Case holding: low high dropped out (>50%)
Low cure rate (< 50%)

SITES OF DIAGNOSIS OF TB
IN HOSPITAL
District Health
Service
Hospitals
Lung Clinics
PPTI Clinics,
WP,Lapas/Rutan
Community
Leader
PKK, PPTI
NGO
Private Doctors
CHC
PRM / PPM
EXTERNAL NETWORKING
Option of TB management in HDL

Option Suspect
finding
Diagnosis Treatment
initiation
Continuing
treatment
Consultation Recording
and
reporting
1.
2.
3.
4.
Hospital/non PHC
PHC
Alur Rujukan Penderita Tuberkulosis
Rumah Sakit Puskesmas
Koordinator
HDL Kab/Kota
Penderita, OAT,
TB.01, surat
rujukan (TB.09)
Wasor TBC
Kab/Kota
informasi
konfirmasi
(TB.09)
REFERAL SYSTEM IN HDL
World problems of Tuberculosis (TB)
The second global cause of death from infectious
agents
Neglected Childhood TB
Low Case Detection Rate
Lack of holistic approach of TB management
Non-standardized management



Non-standardized management
Diagnosis
Treatment
Public Health
irrational treatment
over diagnosis

underdiagnosis
contact tracing

Recording and reporting
ISTC
(International Standard for TB care)
Differ from existing guidelines
standards what should be done
guidelines how the action is to be accomplished
Evidence-based, living document
As a complementary of the existing guideline
Purpose of ISTC
ISTC

Diagnosis
Treatment
2 standards Public Health
6 standards
9 standards
Standards for Diagnosis
Pediatric considerations
Standard 1
All persons with
otherwise
unexplained
productive cough
lasting two-three
weeks or more
should be evaluated
for TB
COUGH is NOT the main
symptom of TB
Other symptoms should
be considered:
weight loss or FTT in
the last two months
fever >2 weeks with
unexplained causes
Close contact with
adult Pulmonary TB
Pediatric consideration
Standard 4
All persons with
chest radiographic
findings suggestive
of TB should have
sputum specimens
submitted for
microbiological
examination.
Collecting sputum in
children is challenging


If possible,
perform induced sputum
or gastric lavage
Pediatric consideration
Standard 6
The diagnosis of
intra-thoracic TB in
symptomatic
children with
negative sputum
smears should be
based on the
finding of chest
radiograph
The appearance of
lymphadenopathy is
subtle and may be
difficult to detect
especially in
malnourished children
and when there is HIV-
related pulmonary
disease.
Pediatric consideration
Standards for Treatment
pediatric considerations
Standard 8
All patients (incl those
with HIV infection) .....
regimen using drugs of
known bioavailability.
The initial phase should
consist of two months
of isoniazid, rifampicin,
pyrazinamide, and
ethambutol.


Triple drugs:
INH, Rif and PZA

Four or five drugs
for severe TB
Pediatric consideration
Standards for Public Health
ISTC Standard 16
All providers of care for patients with TB should
ensure that persons (especially children under 5
year of age and persons with HIV infection) who are
in close contact with patients who have infectious
TB are evaluated and managed in line with
international recommendations.
ISTC Standard 16
Children under 5 years of
age and persons with HIV
infection who have been
in contact with an
infectious case should be
evaluated for both latent
infection with M. tb and
for active TB.
ISTC Standard 17
All providers must report
both new and retreatment
TB cases and their
treatment outcomes to
local public health
authorities, in conformance
with applicable legal
requirements and policies.
Together in partnership we are more
than the sum of our parts!