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DYAH ERTI MUSTIKAWATI

KASUBDIT TB, DIREKTORAT PPML


KEMENTRIAN KESEHATAN RI
Makassar, 23 Juli 2014
Overview

 Overview of global burden of TB

 Tantangan Pengendalian TB
 Model pendekatan PPM Komprehensive

 What future for TB control: is elimination possible in our


lifetime?
Estimated TB incidence rate, 2012

Americas
Europe

Ref: Global TB Control Report 2013


3%
4%
E. Mediterranean
8%

South-East Asia
39%

Africa
27%

38% in India + China


26% in India Western Pacific
19%
2012: Estimated number of MDR-TB Cases out of notified TB cases - 80%
of all cases are in 12 countries
Russian Fed.: 46,000
(15%)

Ukraine: 6,800

China: 59,000
(20%)
Kazakhstan: 8,800
Philippines: 13,000
Uzbekistan: 4,000

Pakistan: 11,000 India: 64,000


(21%)
South Africa: 8,100
Indonesia: 6,900

Bangladesh: 4,200 Myanmar: 6,000


92 countries notified at least one case of XDR-TB

Ref: Global TB Control Report 2013


TB cases and deaths, 1990–2012: achievements of control efforts with
available tools (absolute numbers)

Incidence Mortality

Ref: Global TB Control Report 2013


5

Incidence peaked at 9 million in early 2000s


8.6 million in 2012
Total mortality peaked early 2000s at 1.8 million
1.3 million in 2012
The case detection/notification gap, 2012

Nearly 3 million TB cases either


8.6 not notified or not detected
2.9 million missed
NO elimination without
5.7 “capturing” them

Global notifications
Estimated incidence
Ref: Global TB Control Report 2013
Global Progress on impact - 2012
TARGETS ON TRACK
5 PRIORITIES FOR ACTION
Incidence falling slowly: 2015
Reaching the “missed” cases (3
MDG on track
million not in the system)
Reduction in TB mortality of
Address MDR-TB as crisis
45% since 1990
Accelerate response to TB/HIV
22 million lives saved since
1995
Increase financing to close resource
gaps
87% cure rate and 56 million
patients cured, 1995-2012
Ensure rapid uptake of innovations
Ref: Global TB Control Report 2013
Overview

 Overview of global burden of TB

 Tantangan Pengendalian TB
 Model pendekatan PPM Komprehensive

 What future for TB control: is elimination possible in our


lifetime?
Disease burden among Top 6 HBC 2012
(rate/ 100,1000 population)
Population Mortality Prevalence Incidence HIV + incident
Population Mortality Prevalence Incidence HIVTB
+ cases
incident TB
India 1,236,687 22 230 176 cases
5.95

China India 1,236,687


1,377,065 3.222 230
99 176
73 5.95
0.73
China 1,377,065 3.2 99 73 0.73
South Africa 52,386 59 857 1,000 63
South Africa 52,386 59 857 1,000 63

Indonesia Indonesia 246,864


246,864 27 27 297
297 185
185 1.65
1.65

Pakistan Pakistan 179,160


179,160 34 34 376
376 231
231 0.92
0.92
Bangladesh 154,695 45 434 225 <0.1
Bangladesh 154,695 45 434 225 <0.1
Situasi TB-HIV
Indonesia merupakan negara yang masuk dalam kategory
High Co-infected Rate untuk TB-HIV, dengan demikian
populasi ODHA di Indonesia sangat rentan terhadap
penularan TB dan ko-infeksi TB.

*) TB Global Report 2013


CNR330
ribu/ TSR
90%
6.9 Angka Kejadian, Prevalensi dan Tingkat Kematian akibat Tuberkulosis
6.10 Proporsi jumlah kasus Tuberkulosis yang terdeteksi & diobati dalam program DOTS
CAPAIAN INDONESIA TARGET
ACUAN STA
INDIKATOR MDG’S
DASAR 2011 2012 2013 TUS
2015
Angka Kejadian 187 185 185 Menu run ●
Tuberkulosis (semua 343 (Laporan TB Global (Laporan TB, Global Report (Laporan TB, Global
6.9a WHO, 2013) Report WHO 2013)
kasus/100.000 (1990) WHO 2013)
penduduk/tahun)
6.9b Tingkat Prevalensi 443 214 213 297 221 ●
Tuberkulosis (per 100.000 (1990)
penduduk)
6.9c Tingkat Kematian karena 27 27 27 46 ●
Tuberkulosis 92 (Laporan TB Global (Laporan TB Global WHO, (Laporan TB Global
(1990) WHO, 2013) 2013) WHO, 2013)

6.10a Proporsi jumlah kasus 20% 83,5% 84,4% 78,8% 70% ●


Tuberkulosis yang (2000) (Laporan Kemenkes (Laporan Kemenkes (Laporan Kemenkes RI
terdeteksi dalam program RI 2011) RI 2012) Per 31 Jan 2014)
DOTS
6.10b Proporsi kasus 86% 90,3% 90,2% 90,5% 85% ●
Tuberkulosis yang diobati (2000) (Laporan Kemenkes (Laporan Kemenkes (Laporan Kemenkes RI
dan sembuh dalam RI 2011) RI 2012) Per 31 Jan 2014)
program
Sumber : Direktorat DOTS Penyakit Menular Langsung (Capaian MDGs menurut Global Report , Modeling, dan Surveilans)
Pengendalian
Ket : ● On track ● Off track GOAL 6 PROGRAM TB
ANGKA NOTIFIKASI KASUS TB BTA POSITIF DAN SELURUH KASUS
Per 100.000 penduduk, Indonesia, 2005 – 2013

136 135
125 131 129 132
122 127
119

79 78 83 83 79
72 71 73 73

BTA Positif Baru Semua Kasus

2005 2006 2007 2008 2009 2010 2011 2012 2013


Overview

 Overview of global burden of TB

 Tantangan Pengendalian TB
 Model pendekatan PPM Komprehensive

 What future for TB control: is elimination possible in our


lifetime?
Some Proportion of TB Patients seek Health to Private Practitioners*
100%
90%
80%
70%
Lain-lain
60% RS khusus paru
50% Praktik swasta
40% Puskesmas
30% RS swasta

20% RS pemerintah

10%
0%
Jawa Bali Kalimantan Papua Sumatra Sulawesi

*Riskesdas 2010, Balitbangkes (2011)


TB Drugs Consumption at Private Market/Sectors*

Country Incidence Consumption of TB drugs 1st line Proportion of


at private market (%) loose TB drugs (%)

India 1,982,628 117 23


Indonesia 429,730 116 91
Filipina 257,317 86 16
Pakistan 409,392 65 36
China 1,301,322 23 98
Thailand 92,087 17 94
Russia 150,898 13 100
Vietnam 174,593 7 90
Bangladesh 359,671 7 11
Africa Selatan 476,732 3 34

*Wells et al (2011)
DST Profile
Table: Drug resistance profiles for PMDT patients; First- and second-line DST
from PMDT suspects from RS-Soetomo and tested at BBLK Surabaya, 2013

MDR [N] (%) Res to Ak Res to K Res to Ofl Pre-XDR XDR


Profile

HR 25 (46.3) 0 0 2 2 0

SHR 6 (11.1) 0 0 0 0 0

HRE 16 (29.6) 0 0 6 6 0

SHRE 7 (13.0) 0 0 4 4 0

TOTAL 54 0 0 12 12 0
(22.2%) (22.2%)

Drug resistance profiles for PMDT patients; First- and second-line DST by BLK
Bandung, 2013

MDR [N] (%) Res to Ak Res to K Res to Ofl Pre-XDR XDR


Profile

HR 16 0 0 5 5 0

SHR 7 0 0 0 0 0

HRE 28 5 4 13 8 5

SHRE 55 5 6 26 22 5

TOTAL 106 10 10 44 35 10
(9.4%) (9.4%) (41.5%) (33.0%) (9.4%)

Richard Lumb, Ofloxacin resistance in Indonesia


DST Profile
Table: Drug resistance profiles for PMDT patients; First- and second-line DST
from PMDT suspects from RS-Soetomo and tested at BBLK Surabaya, 2013

MDR [N] (%) Res to Ak Res to K Res to Ofl Pre-XDR XDR


Profile

HR 25 (46.3) 0 0 2 2 0

SHR 6 (11.1) 0 0 0 0 0

HRE 16 (29.6) 0 0 6 6 0

SHRE 7 (13.0) 0 0 4 4 0

TOTAL 54 0 0 12 12 0
(22.2%) (22.2%)

Drug resistance profiles for PMDT patients; First- and second-line DST by BLK
Bandung, 2013

MDR [N] (%) Res to Ak Res to K Res to Ofl Pre-XDR XDR


Profile

HR 16 0 0 5 5 0

SHR 7 0 0 0 0 0

HRE 28 5 4 13 8 5

SHRE 55 5 6 26 22 5

TOTAL 106 10 10 44 35 10
(9.4%) (9.4%) (41.5%) (33.0%) (9.4%)

Richard Lumb, Ofloxacin resistance in Indonesia


Key approach:
1) System strengthening, 2) Enforcement of regulatory foundation, 3) Inclusivity and integratio, 4). Grab Momentum
The size and the role of, and contribution to TB control, of the identified provider group

Health Providers: Total DOTS


Indonesia # %
Primary Health Care 8875 8875 100%
Lung Clinics / Hospitals 37 37 100%
Public Hospitals 533 458 86%
Private Hospitals 867 314 36%
Military/ Policy Hospitals 181 95 53%
Para-Statal Hospitals 63 29 46%
Prisons 270 168 62%
Private Practitioners >80.000 315 0.3%
NGOs 11 -
Workplace 29 -
PPM Contribution 2012
Country Provider Group including No. of cases No. of cases % of contribution
large hospitals contributed by contributed from non-NTP
non-NTP public by non-NTP providers to total
providers private, corporate case notification
and voluntary
providers

Indonesia •PHCs: 8875 •Prisons: 451 •PPs: 4971 25%


•PPs: 315 •Hospitals: 68,397 •Workplace: 345
•Prisons: 168 cases •NGO: 116
•Hospitals: •Lung Clinics:
a.Private Hosp: 314 8,528 cases
b.Public Hosp: 458
c.Parastatal Hosp: 29
d.Military/ Police Hosp: 95
•Lung Clinics/ Hosp: 36
Pilihan fasyankes dalam menatalaksana pasien TB paru
non komplikasi

Penemuan Mulai Pengobatan Konsultasi Pencatatan


Pilihan Diagnosis
terduga Pengobatan selanjutnya Klinis dan Laporan
1
2
3
4
5
6
7

di Fasyankes Primer (pasien non peserta JKN)


di Fasyankes Primer (pasien peserta JKN)
di Fasyankes Lanjutan
di Puskesmas
Pillar 1:
Basic DOTS at Primary Health Care (Puskesmas)
Challenge Action Way Foward
TB Service Quality: Improving quality of TB services at PHC: • 100% of EQA coverage by
• Limited coverage of Labs • Expand new TB EQAS system to cover more than 2016
EQA in PHC (50%) 5000 microscopic centers at PHC level. • SITT phase 2
• No Real time information • Expand Implementation of electronic TB information implementation (including
system system to PHC level. for PHC), will be started on
• Lack of funding for TB Health • Utilization of PHC operational budget (BOK) to January 2014
promotion and tracing support health promotion and patient tracing • Revise guidance for PHC
• Only focused on New Smear activities, including activities to reach the unreached budgeting tools to support
Positive cases population TB control program
• Limited supervision from • Case finding intensification for all forms of TB in • TB supervision tools has
district PHC level. been updated.
• Increase budget available for supervision and
improve quality of supervision.

Low coverage of TB HIV • Collaboration strengthening with NAP for “test and Started for 10 high burden
services, only focused in treat” initiation districts in 2013 and expands
hospitals • New policy of CoC decentralized up to Puskesmas gradually to 75 district
level
Pillar 2:
Public/ Private Hospital Services
Challenge Action Way Foward
• Lost to follow up rates in hospital • Newly updated SPM (Minimum Service Standards) guides • Implementation of new
still high, it has decreased, from local government and public hospital to implement SPM in the next fiscal
48% to 15% in the last 10 years. standard TB control. years.
• Hospital currently contributed • Development of New Hospital Accreditation which include • Support to National
approx. 25% of TB cases in the TB control requirements hospital accreditation
country. But only 58% of hospitals • Development of PNPK (National TB Medical Services committee.
has been engaged since 2001. Guideline) as reference for Hospital SOP and Clinical • Implementation and
• JEMM 2013 found under reporting Pathway as mandated by health regulation and hospital monitoring of the new
of TB cases in all hospitals visited, law to assure quality of services. PNPK and managerial
especially for paediatric, smear • New Managerial Guidance for Hospital Manager/owners. guidance
negative and extra pulmonary TB • Updated supervisory tools for Hospital DOTS • Ensuring the component
• Financing issues for service fees implementation for standard TB care are
and operational cost • Integration of TB Surveillance system (SITT) into National covered by BPJS
Health Information Systems (NHIS) mandated for scheme.
hospitals.
• Take momentum for TB financing through new Health
financing system schemes (BPJS).
Pillar 3:
Private Practitioners and Specialists
Challenge Action Way Foward
• Only 0,3% (315/>80.000) of • Preparation for Mandatory Notification. • Mandatory notification
Private practitioners (stand • Transformation of ISTC ver.2 to PNPK as required by will started at 2015,
alone doctors) are reporting Health regulation for strong impact. preparation needed:
to NTP. • New TB training system for private practitioners: Faculty legal aspects, ME
• Estimated 30% of TB cases of Medicine curricula (Pre service training) and Self systems.
goes to private practitioners financing training (In service training). • Dissemination of the
• Development of the new accreditation and reward new PNPK.
systems for private practitioners, also related with new • Pool of trainers
Health financing system schemes (BPJS). preparation for
• Best fit models search for effective engagement: independent training.
a. Expansion of Private practitioners involvement under • Evaluation of new
collaboration with ATS, Indonesian Pulmonology initiatives.
society and Indonesian Medical association. • PPs at 12 top priority
b. Social business model under collaboration with TB provinces will be
REACH engaged by 2016
Pillar 4:
Qualified TB Diagnostics
Challenge Action Way Foward
• Only 6 provinces • Lab strengthening and country wide expansion of LQAS, • Speed up the expansion
implementing new LQAS supported by TB CARE I and GF. of LQAS, not sequential
system • Development of road map and long term plan for TB lab as before
• Dependency to external expansion with targets: • Preparation of BBLK
supra national laboratory a. 1 Supra national lab before 2016 Surabaya as a candidate
• Private laboratory are not b. Ratio for lab culture and DST meet with regional for supra national lab
quality assured target by 2016. • Speed up preparation
• Non standard lab methods • Involvement of Lab association (ILKI) and Lab technician process for 18 new labs
are widely available in association (PATELKI) under collaboration with Lab for culture and DST
private sectors directorate-MoH. • Develop regulation for
• Ratio of lab: • Ban for non standard serology examination quality assurance
a. Smear: 1 for 55.000
population
b. Culture: 1 for 22 million
c. DST: 1 for 49 million
Pillar 5:
Quality of ATD and Rational Drug use

Challenge Action Way Foward


• Unknown but huge • Collaboration with BPOM to regulate the market to • Establish regular coordination
uncontrolled TB drug protect TB patient (quality approach). and communication with
available in free market. • Regular pre and post market quality assurance for BPOM
• Limited quality assurance ATD provided by PPOM. • Secure funding for pre and
for ATD provided by • Assist local drug manufacturers to obtain WHO post market QA
program (pre and post PQM, supported by USP/USAID. • At least 2 out of 3 potential
market) • Collaboration with all pharmacist professional candidates could pass PQM
• All FLD TB drugs provided organization (IAI) to support TB program in their by end of 2015.
by GoI but it should follow respective areas such as manufacture, distribution • Enhance contribution and
country regulations. and drug dispensing. engagement of Indonesian
Pharmacist association in
PPM-TB
Pillar 6:
Community Strengthening

Challenge Action Way Foward


• Still limited in scope • Establishment of Stop TB Partnership forum Indonesia to • Monitoring Progress
• Mostly on local advocacy engage broader CSOs and community . • Intensify coordination
and DOTS implementation • Development of National CSO plan which cover broader • Documenting lesson
(community case finding issues: learnt/ best practices
and holding, treatment a. ACSM • Strengthening
support) b. Support service delivery to unreached population. networking and data
• Only few support on TB- c. Increase role of specific NGO/ CSO on specific area to base dissemination to
HIV,TBMDR, prison works, support TB Program, i.e: IMA, IAI, PDPI, PPNI, DPKR, ensure prompt and real
PLHIV network, TB patient etc. time public monitoring
network • Strengthen capacity of CSOs and community on watch
advocacy and community funding mobilization through • GIS mapping of Quality
various resources: CSR, BAZIS, Dompet Duafa, Church TB Services
association, Budha Tsu Chi, etc.
A new direction and opportunity
Sustainable Financing for TB in Indonesia
Government Budget UHC/ BPJS Community Funding

Resources Central, Provincial, Central Government Private/Public CSR,


District budget Charity, BAZIS (Zakat,
Infaq, Shadaqah), etc

Allocations Program operational Diagnostic and Income generation,


cost (training, Treatment service fee shelter/ dormitory, socio-
supervision, meeting) , economic supports,
drugs, reagent, etc. patient’s allowance
Mainstreaming TB under
Universal Health Coverage (BPJS) 1
 Government owned Health Insurance System
 The initial phase of BPJS will start in 2014-2016,
 Full implementation from 2019 onwards.
 Initial phase will cover 111 million population:
– 25 million employees paying their own premium. and
– 86 million poor population covered by government
 Stepwise increase to reach Universal Coverage.
Mainstreaming TB under Universal Health Coverage
(BPJS) 2
 TB is included but the package and coverage for TB still needs to be
negotiated.
 Health Providers in the BPJS: Primary Health Care units , Hospitals
(Public/ Private), Private providers (Stand alone), Clinics  need to
be accredited first
 Timeline for TB:
– 2014-2016: Transition phase to gain best fit model, all diagnostic and
treatment cost covered by BPJS, minus ATD and reagents (these will be
provided directly by MoH).
– After 2016, all cost for ATD and reagent will be topped up to BPJS,
while MoH will focus on coverage of Programmatic aspects
Overview

 Overview of global burden of TB

 Tantangan Pengendalian TB
 Model pendekatan PPM Komprehensive

 What future for TB control: is elimination possible in our


lifetime?
Post-2015 Global TB Strategy
Proposed Pillars and Principles

Integrated, Bold policies and


patient- supportive Intensified
centered TB systems research and
care and innovation
prevention
Post-2015 Global TB Strategy
Proposed Pillars
Targets: 95% reduction in deaths and 90% reduction in incidence (<
10 cases / 100,000 population) by 2035

Integrated, patient-centered TB Intensified Research and


Bold policies and supportive systems
Care and Prevention Innovation

Government stewardship , commitment, and


Early diagnosis of TB including universal adequate resources for TB care and control with
drug-susceptibility testing ; systematic monitoring and evaluation
screening of contacts and high-risk groups Discovery, development and rapid uptake of
new tools, interventions and strategies
Engagement of communities , civil society
organizations, and all public and private care
Treatment of all forms of TB including drug - providers
resistant TB with patient support
Universal health coverage policy; and regulatory
Collaborative TB/HIV activities and framework for case notification, vital registration,
management of co-morbidities drug quality and rational use, and infection control Operational research to optimize
implementation and impact, and promote
innovations
Preventive treatment for high-risk groups Social protection, poverty alleviation, and actions
and vaccination of children on other determinants of TB
With current incidence decline: 2015 MDG target reached but TB not
eliminated by 2050

Current rate of decline -2%/yr

China, Cambodia: -4%/yr

W Europe after WWII: -10%/yr

US and Canada Eskimos, 1950s-60s:


-17%/yr

Elimination target:<1 / million / yr


-20%/yr
What is needed to accelerate incidence decline and target
"elimination"?
 Economic development: better nutrition & housing
 Universal health coverage & social protection
 TB care widely accessible to all and of high-standards
 Focused, high-intensity interventions
 Screening of high-risk groups and mass TLTBI
 Infection control practices

However… while incidence decline can accelerate, “elimination” is another story, as it


requires major reduction of:
(i) transmission rate, and
(ii) reactivation of latent infection among the already infected

This translates into…new tools and increased financing


Pipeline promising, but what do we need to eliminate TB?
Potential impact of new tools on TB incidence in S-E Asia

To eliminate TB:

Source: L. Abu Raddad et al, PNAS 2009


1. Very short potent regimen for all forms, and
2. Simple regimen for mass chemoprophylaxis

Synergy of interventions !
Action on both transmission and reactivation
•Led & NAAT at microscopy lab level
•Dipstick at point of care
pathways
•Regimen 1 = 4-month, no effect on DR
•Regimen 2 = 2-month, 90% effective in M/XDR
•Regimen 3 = 10-day, 90% effective in M/XDR

Or:
Mass pre- and post-exposure vaccine

Add. Effects = effects also on latency


and infectiousness of cases in vaccinated
Xpert: updated WHO Recommendations, 2013

1. Xpert MTB/RIF should be used as the initial diagnostic test in individuals suspected of having MDR-TB or
HIV-associated TB. (Strong recommendation)

2. Xpert MTB/RIF may be considered as a follow-on test to microscopy in settings where MDR-TB or HIV is
of lesser concern, especially in further testing of smear-negative specimens. (Conditional
recommendation acknowledging major resource implications)

3. Xpert MTB/RIF use also expanded to for use in childhood TB and extrapulmonary TB
Keywords: Detect, Cure and Prevent
 Ditingkat Global 1/3 penduduk dunia pernah terekspose TB dan
dinegara HBC diestimasikan lebih dari 50%
 Negera HBC mempunyai keterbatasan sumber daya  menetapkan
skala prioritas pada detect dan cure!!
 Perkembangan teknologi baru harus mengarah ke Patients’ orientation
 Manfaat yg diperoleh oleh masyarakat
 Peran Organisasi Profesi  benchmarking new tools/technologies for
the greatest benefit of the patients (keberpihakan kepada kepentingan
pasien)