[Any correction on incorrect grammar or vocabularies will be greatly appreciated]
By: M. Sholekhudin
Indonesia still ranks third in the world for tuberculosis (TB) burden. In other hand, effective method of TB therapy has been established clearly. Standard operating procedure of the therapy has also been published by Indonesian Ministry of Health. If so, what is the problem?
“The problem is that many health providers still use non-standard methods!” Jane Soepardi MD answer the question in short and firm sentence. Jane is the Director of Tuberculosis Control and Prevention, Ministry of Health.
The standard method that Jane meant was Pedoman Nasional Penanggulangan Tuberkulosis (Operational Guide for National Tuberculosis Control Program), published by Ministry of Health. It is the only guide recommended for all health providers throughout Indonesia. Any textbooks other than this guide is not suggested to be referred.
Why do we have to use one guide? It is because TB is a public health problem and government is responsible for its control. Therefore, all parties concerned for its control have to refer to the guidelines stated by Ministry of Health. TB is different from other diseases such as hypertension or diabetes. There is not standard method of these diseases. Doctors are responsible for the method of therapy.
This standard method is known as DOTS (Directly Observed Treatment, Short-Course) strategy, contains five main keys. The first key, commitment from all parties concerned to TB control, including government and health providers. This commitment is important because control method of TB is actually simple but needs strict discipline from all parties.
The second key, main test for TB diagnosis is microscopic sputum examination. In this test, three spot of sputum specimens from patients are collected from three different times. Mycobacterium tuberculosis in the sputum is then examined under microscope. In Indonesia, according to Jane, many doctors diagnose TB only from chest X-ray in spite of fact that X-ray does not always give specific image of pulmonary TB.
It does not mean that we do not need chest X-ray examination. X-ray test still can be conducted, but it is not the main test. It does not also mean that sputum test is the only examination. In some cases, for example TB in child, diagnose is conducted after several kind of tests.
The drug in one caplet
The third key in DOTS strategy, the drugs used in TB therapy must be in standard preparation. Anti-TB drugs (ATD) are isoniazid, rifampicin, pyrazinamide, streptomycin, and ethambutol. These ATD are used in combination in single preparation containing several ATD.
In the past, these ATD were available in separated tablet or capsule. It is confusing for patients and even for health workers. Patients must take many tablets or capsules everyday. This problem will not happen if the doctor give them standard ATD in single preparation because one caplet contains four kind of ATD.
Patients need only take one caplet each dose, based on their body weight. They will not be confused by four tablets or capsules in each dose. Jane said, many Indonesian doctors still prescribed ATD in non-standard preparation for their patients. They prescribe several ATD in separated tablets or capsules.
The main problem in TB therapy is patient’s obedience of taking medication. As we know, ATD must be taken completely for 6 – 8 months. Patients often feel bored and stop taking the drugs in the second month because they think they have been healthy and recovered from TB.
They don’t realize that “feeling healthy” does not always mean recovering from TB. Mycobacterium tuberculosis can lie dormant in their body and still infectious if they do not take ATD completely until 6 – 8 months.
Patient’s disobedience is the biggest problem in TB therapy. It can cause TB bacteria resistant to ATD. If it happens, the next therapy will be more complicated, longer, and more expensive. Moreover, the patients will be more dangerous because they spread resistant TB bacteria to others. It is obviously a serious problem.
DOTS strategy overcomes this problem through “embedded supervision”. Every patient has to have a personal companion called drug-taking supervisor (DTS). A DTS is usually a family member of patient. He or she will be trained by health worker in public health center. His or her duty does not only to act as alarm clock to remind the patient to take the drug, but to supervise and make sure that the patient really takes the drug in discipline way.
Public health center is more competent
TB control needs commitment from all parties concerned. Patients have to take ATD in discipline way and, at the same time, government and all health providers have to make sure that standard ATD is always available. It is the fourth key in DOTS strategy.
But—it is the bad news—many health providers in our country has not adopted DOTS strategy yet. If so, what can patients do to get standard therapy based on DOTS? The answer may sound surprising: instead of visiting hospitals, see the doctor of public health center (Puskesmas). Yes, come to the health center that we often underestimate it.
Compared to hospital, Puskesmas have many advantages in the case of TB control. Puskesmas is the main operational health center, it spreads throughout Indonesia. About 98% Puskesmas have adopted DOTS strategy. Only 2% (usually located in remote areas) have not adopted it yet. Meanwhile, about 60% of hospitals in Indonesia have not adopted DOTS strategy yet.
Patients do not need to be afraid if—let say—they need special treatment that Puskesmas does not have its facilities. If it happens, Puskesmas will refer patients to the hospital that has already adopted DOTS strategy. Puskesmas has surely link to the DOTS-adopting hospitals.
Today, it is still difficult for us to differentiate hospitals that have or have not adopted DOTS strategy. There are not visible DOTS sign in front of hospital. However, Ministry of Health will soon regulate DOTS-adopting health providers. In the future, we can differentiate health providers that have or have not adopted DOTS from its visible sign.
The drug is for free
In the case of TB control, Puskesmas also have another advantage: the ATD is for free. Patients do not need to pay it because government is responsible for providing the drugs. Moreover, if patients come to Puskemas, they help government indirectly to monitor National TB Control Program because all data about TB patients in Puskesmas are recorded nationally. This traceable documentation is the fifth key in DOTS strategy.
Puskesmas will monitor patients progress until they are stated clearly recover from TB. If a patient does not return to Puskesmas in the time scheduled, Puskesmas will search him or her to make sure that the patient takes the drug completely. In some Puskesmas, all patients and DTS have to sign written agreement to make sure patients take ATD completely.
TB is a serious problem. This disease spreads easily through cough droplet. According to WHO Global Tuberculosis Control Report (2008), TB prevalence in Indonesia is estimated about 234/100,000. Every one patient can spread the infection to 10 – 15 people every year. That is why this disease must be controlled by national integrated program.
DOTS strategy has been proven effective in controlling TB. In order to succeed nationally, all health providers must refer to Operational Guide for National Tuberculosis Control Program. “It is not only a textbook, but a written guide to obey,” Jane stated once again firmly.
In Indonesia, almost all people have ever been exposed by TB bacteria although it does not always develop into disease. Mycobacterium tuberculosis usually infects lungs with symptoms: productive coughing that last for 2 – 3 weeks, coughing up blood, fatigue, unexplained weight loss, night sweats, and fever more than one month. If these symptoms appear, see the doctor of Puskesmas.
TB bacteria can also infects bone, kidney, lymph gland, and other part of body. The symptoms vary according to the organ infected. For example, tuberculosis of the spine may cause pain like rheumatoid arthritis. To prevent bacteria transmission, TP should cover mouth and nose while coughing, put the sputum into special desinfected container, and then put it away into closet.