High tuberculosis notification and treatment success rates

through community participation

in central Sulawesi, Republic of Indonesia

SETTING:
Central Sulawesi Province, Republic of Indonesia.
OBJECTIVE:
To increase tuberculosis case notification and maintain high treatment success rates through
com- munity participation in a tuberculosis field programme.
DESIGN:
Comparison of tuberculosis case notification and treatment results in a community based
tuberculosis programme (CBTP), before and after introduction of the programme and
between areas where the programme was and was not introduced.

RESULTS:
During 1998, the CBTP was introduced in two of the four rural districts of the Central
Sulawesi province, covering 224 (29%) of the 772 villages and 362 700 (33%) of the 1 109
100 population in these dis- tricts. In the CBTP villages the notification rate of new smearpositive patients per 100 000 population in- creased from 51 in 1996 and 48 in 1997 to
166 in 1998. In the 548 non-CBTP villages the rates were 62, 60 and 70, respectively. The
sputum conversion rate at the end of the first 2 months of the treatment was over 85% in both
the CBTP and the non-CBTP villages. In the CBTP villages the treatment success rate (cure
and treatment completion) was 90.4%, 89.5% and 93.7% in 1996, 1997, and 1998. For
the non-CBTP villages these rates were respectively 85.4%, 86.8% and 85.9%. In 1998 the
sputum conversion and treatment success rates were significantly higher in the CBTP villages
than in the non- CBTP villages.

CONCLUSION:
Through community participation, the notification of new smear-smear positive patients
in- creased substantially, while sputum conversion and treatment success rates remained high.

KEY WORDS:
tuberculosis control; community partici- pation; community based tuberculosis control;
case no- tification; treatment results

Indonesia adalah salah satu negara dengan kasus tuberkulosis terbanyak. Pada tahun
1999, WHO memperkirakan ada 590.000 orang yang terkena tuberkulosis di Indonesia tiap
tahunnya yang sama dengan 282 per 100.000 populasi. Insiden pada pasien dengan smear TB
positip diperkirakan ada 265.000 yang terdiagnosa Tb, yang sama dengan 127 per 100.000
populasi
Tahun 1993, dilakukan program yang pertama tiap minggunya dengan mengobservasi
langsung pemberian terapi yang dilakukan oleh petugas kesehatan selama awalan 2 bulan dan
lanjutannya 4 bulan. Hal tersebut, diterapkan oleh semua 103 pusat kesehatan di Pusat
Provinsi Sulawesi pada tahun 1995.
Sejak dimulainya program, rasio penilaian hasil sputum yang positip TB diantara
semua pasien adalah 80% atau lebih. Sedangkan, rasio kesuksesan terapi (dikonfirmasi
dengan pemeriksaan bakteriologi dan terapi lengkap) sekitar diatas 85%.
.
The annual incidence of smear-positive pulmonary cases in Central Sulawesi is not
known. For the calcu- lation of notified patients as a percentage of estimated patients, the
average national annual incidence of smear-positive tuberculosis cases of 127/100 000
pop- ulation was used as denominator. Based on this it was concluded that fewer than 50%
of smear-positive pa- tients are detected. From discussions with supervisors and health centre
staff it was concluded that the ser- vices were not reaching the people in remote areas
who depended mainly on sub-centres that did not provide tuberculosis control services.
Furthermore, cultural beliefs, shame at being known to be tubercu- lous, lack of money to
pay for transport to attend a health centre, and lack of awareness about free diag- nosis and
treatment may prevent patients from com- ing forward for diagnosis and treatment.
In order to increase notification of smear-positive patients and maintain high
treatment success rates a community based tuberculosis programme (CBTP) was
introduced in 1998. This paper describes the steps that have been taken to mobilise
communities on tuberculosis and train sub-centre health workers in delivery, observation
and recording of treatment. Notification data on new smear-positive patients and treatment
results before and after introduction of the CBTP are presented and discussed. The data of
the CBTP villages are compared with those of the remain- ing villages (referred to as nonCBTP villages).

SETTING
The Central Sulawesi province consists of five dis- tricts, four rural districts and
a municipality, with a total population of just over 2 million at the end of 1998.
Details about detection, diagnosis and treatment of tuberculosis patients before
the CBTP was intro- duced have been published previously.2 In short, case- detection is done
through sputum smear examination of patients presenting at a health centre with suspect
tuberculosis, diagnosis is by sputum smear-micros- copy carried out in selected health
centres, and treat- ment is given in all health centres upon prescription by a medical officer
or trained nurse. All patients with a diagnosis of new smear-positive tuberculosis are
treated daily with four drugs (rifampicin, isoniazid, pyrazinamide and ethambutol) for the

first 2 months, followed by rifampicin and isoniazid three times weekly for 4 months.
At the onset of treatment a box of drugs is reserved for each patient. The patient is requested to identify a household member or other community member for observation of
treatment at home, six times per week during the first 2 months and five times per fortnight
during the last 4 months. Drugs are provided in blister packs containing the drugs for one
day.
Samples of smears for all smear-positive patients and for 10% of smear-negative
suspects are routinely re-examined by provincial laboratory technicians, with the readers
being blinded to the result of the pe- ripheral laboratory. Over the years concordance of
results between the peripheral laboratories and the reference laboratory has been over 95%.

METHODS
During 1998 the CBTP was introduced in 224 (29%) of the 772 villages of two
rural districts, covering 362 700 (33%) of the 1 109 100 population of these districts.
To select participating communities, and to mobil- ise and train the community and
sub-centre health workers, the following steps were taken:
Health centres were selected by provincial and dis- trict staff. Selection criteria were
higher-than-average treatment resultssputum conversion and treatment outcomeduring
the previous 2 years. The provincial and district tuberculosis supervisors and health
centre staff met to discuss the purpose of the CBTP, after which villages were selected by
health centre staff and approved by the district supervisor.
Health education was provided and information disseminated to the leaders of the
selected villagers, including the village heads, religious leaders and members of special
groups such as Womens Associa- tions. Health education was also provided to the
community, in co-operation with the leaders, in order to: 1) convince the people that
tuberculosis is a village health problem and that infectious tuberculosis patients can infect
their family and community members;
2) explain about the disease, its symptoms, and diag- nosis; 3) explain that the
disease can be cured, that di- agnosis and treatment are available free of charge, and that
treatment can be most successful through commu- nity participation, and 4) encourage
patients with chronic cough to go to the village hall or health centre to have their sputum
taken for examination.
Sub-centre health workers and village midwives were trained in selection of
tuberculosis suspects, de- livery and observation of treatment, including selec- tion and
guidance of household members, and record keeping.
After diagnosis at a health centre or hospital the patients are registered at the subcentre in their vil- lage. Sub-centres are under the responsibility of a health centre and
they serve a number of villages whose populations vary from a few hundred to sev- eral
thousand. During the intensive phase of treat- ment patients attend the sub-centre
once weekly when the treatment for that day is given under direct observation. During the
continuation phase patients attend the sub-centre every fortnight. The drugs for the

remaining days are given to the patient in blister packs. A household member is requested
to observe the treatment at home; the name of the treatment ob- server is written on the
Patient Record Card.
Diagnosed patients are known in the community, and the members of the
community are expected to support them. Patients who do not want to be known as
tuberculous for whatever reason have the choice of visiting the health centre for weekly and
fortnightly observation of treatment and collection of drugs. They are also requested to
select a household member for observation of treatment at home.
In order to guide and supervise the implementation of the CBTP, health centre staff
visit the villages reg- ularly, initially monthly and thereafter every 2 months. The district
tuberculosis supervisors
supervise the participating health centres with the same
frequency. The health centres in the non-CBTP areas are visited quarterly according to
routine policy. Funds for visits by health centre staff and supervision by tuberculosis
supervisors are obtained from external sources.
The Tuberculosis Treatment Cards, District Tuber- culosis Register, recording and
reporting forms are those
recommended by
the
International
Union Against
Tuberculosis and Lung Disease (IUATLD).3
Notification rates are expressed as numbers of new smear-positive patients notified
during a year per 100 000 population. Sputum conversion data and treatment results
are routinely reported by district for quarterly cohorts of patients. For the purpose of this
study, data on notification, conversion and treatment results were separate for the CBTP
villages and the non-CBTP villages, retrospectively for 1996 and 1997 and
prospectively for 1998.
Conversion and treatment outcome data were en- tered into Epi-Info version 6.0
software (CDC, Atlanta, GA). Treatment outcomes of patients in the CBTP villages were
compared with those of patients in the non-CBTP villages, using the 2 test with differ- ences
at the 5% level being regarded as significant.

RESULTS
For 1996 and 1997 the notification rates per 100 000 population were 51 and 48,
respectively, in the CBTP villages, and 62 and 60 in the non-CBTP villages (Table 1).
During 1998 the rate more than tripled to 166 in the CBTP villages, and increased
slightly to 70 in the non-CBTP villages.
Sputum conversion results at the end of the first 2 months of the treatment are
presented in Table 2. For 1996 and 1997 the conversion rate is higher in the CBTP
villages, but the difference is not statistically sig- nificant. For 1998 the conversion rate is
significantly higher for patients treated in the CBTP villages.
The percentage of patients with positive smears at the end of the first 2 months of
treatment decreased significantly over the years in both the CBTP and the non-CBTP
villages.

Treatment results are given in Table 3.

During the three years covered by the study, the treatment suc- cess rate (cure plus
treatment completion) is above 85% in both the CBTP and the non-CBTP villages. The rate
is higher in the CBTP than in the non-CBTP villages. For 1996 and 1997 the difference is
not sta- tistically significant, but for 1998 the treatment suc- cess rate is significantly
higher in the CBTP villages. The decline in failure rate in both the CBTP and the non-CBTP
villages is statistically significant.

DISCUSSION
When short-course chemotherapy was introduced in Central Sulawesi as part of a
package which has been known as the DOTS strategy since 1996, the first pri- ority was to
cure at least 85% of new smear-positive patients diagnosed at health centres.2 The
extension of the strategy to hospitals and private practitioners led to an increase in casenotification; however, fewer than 50% of estimated smear-positive patients were diagnosed
and treated. Tuberculosis diagnosis and treatment through case finding at health centres
and hospitals apparently does not become accessible to part of the population living in rural
areas.
By involving community health workers and com- munity leaders, identification of
tuberculosis suspects and treatment of patients was made as accessible to the patients as
possible, and the communities assumed re- sponsibility for patient adherence to treatment.
Notifi- cation of new smear-positive patients more than tri- pled in the CBTP villages.
Sputum conversion and treatment success rates rose to over 85%, and, after the CBTP was
introduced, were even significantly higher in the CBTP villages than in the non-CBTP
villages.
We have no explanation for the decline in percent- age of patients with positive
smears at the end of the first 2 months of treatment. The decline in percentage of treatment
failures may be related to the decline in positive smear results at 2 months.
The strengths of the CBTP are that the programme was based on observations by
health workers that the tuberculosis control services do not reach many people in rural areas,
and that it is implemented under rou- tine field conditions. The weakness of the comparison
between CBTP and non-CBTP villages is that the vil- lages were not selected randomly.
Only after the CBTP had been implemented did retrospective analy- sis of conversion rates
and treatment results of 1996 and 1997 show that the differences between the CBTP
and non-CBTP villages were not statistically significant and that comparison after
implementation of the CBTP was therefore justified.
During recent years, community involvement in TB control has been given more
attention. The in creasing number of tuberculosis patients with associ- ated human
immunodeficiency virus infection makes clinic and particularly hospital care in many
countries no longer feasible.47 It is clear that the main role of communities in
tuberculosis care should be to ensure patients adherence to treatment, consequently achieving high treatment success rates.810 In a recent publi- cation, a summary is given of
published studies de- scribing community contribution to tuberculosis care.8

These studies exclusively concern delivery of treat- ment by a community worker,

ranging from lay vol- unteers to village doctors. Satisfactory treatment re- sults with 80
90% success rates are reported. In other studies, special groups of people, such as
students,11 traditional healers,12 or TB clubs13 are used or recom- mended for observation
of treatment.
Very little has been published about experiences with the use of community leaders
to raise awareness about tuberculosis in communities. Raising commu- nity awareness
about the signs and symptoms of a disease and the availability of free diagnosis and
treatment has successfully been carried out by a vari- ety of community leaders in the
control of diseases such as leprosy and malaria.1416
Because tuberculosis is often perceived as a chronic incurable disease,16 increasing
the awareness of signs and symptoms of the disease and the possibilities for cure is likely to
increase the number of patients who attend the services for diagnosis and treatment, as
was shown in Central Sulawesi. Prerequisites are that the diagnostic services can cope with
higher number of smear examinations and that treatment for the in- creased number of
diagnosed patients is guaranteed.
As an ongoing process, community participation is likely to be sustainable, because
community leaders and health workers know the villagers. The following lessons have been
learnt from the experiences in Cen- tral Sulawesi:

Although DOTS had been implemented success- fully in the entire province for
3 years, rural com- munities had little, if any, awareness about the disease or the
availability of free diagnosis and treatment.
CBTP can
success rates.

substantially increase

case notification and ensure high treatment

Community participation may play an important role in making progress to attain

the WHO-recom- mended targets of detecting 70% of smear-positive patients and curing
85% of them.
During 1999 and 2000 the CBTP was expanded. By the beginning of 2001 it
covered 561 (73%) of the
772 villages in the two districts. It has been further in- troduced in the two remaining
rural districts and the municipality, covering 66 (10%) of the 648 villages by the beginning
of 2001. It is the intention that by the year 2005 CBTP will be implemented in all of the
villages in the province.

Acknowledgements
Our thanks go to the provincial and district Tuberculosis/Leprosy supervisors, the
staff of the participating health centres, and the community leaders of the participating
villages for their co-opera- tion, dedication and enthusiasm. The help of Mr P Eilers with statistical analysis has been much appreciated.

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