Cermin Dunia Kedokteran No. 63, 1990 3
Artikel
Tuberculosis Situation in
Indonesia,
,
Singapore, Brunei
Darussalam, and in the Philippines
Dr. Tjandra Yoga Aditama
Pulmonology Department, Faculty of Medicine, University of Indonesia
Pulmonary .Unit-Persahabatan Hospital, Jakarta - Indonesia
ABSTRACT
Tuberculosis is still one of the important public health problem is South East
Asian countries. The prevalence of smear positive tuberculosis in the Philippines is
0.66% (1981 - 1983), in Brunei Darussalam it is 0.037% (1985), in Singapore it is 0.14%
(1975) and in Indonesia the prevalence is 0.29% (1980 - 1982). Tuberculosis is also
one of the important cause of death in this South East Asian region.
Nowadays we have the knowledge and means to cure people from tuberculosis and
thereby to relieve human suffering and to break the chain of transmission of disease.
But, there are now more cases of tuberculosis than ever before, because of population
explosion. There mist be a collaboration among countries in South East Asia
region to fight against tuberculosis.
It has been estimated that, in developing countries, 4 - 5
million highly infectious cases of smear positive tuberculosis
occur each year, with an equal number of less infectious cases,
including those positive by culture only and culture negative
cases, the latter being the most frequent form of pulmonary
disease in children. Thus, each year about 10 million persons
still develop tuberculosis and at least 3 million die from this
disease.
1
Tuberculosis in the world is very unevenly distributed. While
it has been reduced in importance in many economically
developed countries, it continues to be of major concern in many
developing areas of the world.
2
SITUATION IN ASIAN COUNTRIES
The situation of tuberculosis is subject of great concern and
Asia is at the heart of it, it is the most populated area of the
the world, it is also where the highest rate of tuberculosis are
observed and high number of cases were found, two third of all
tuberculosis cases occur in Asia.
3
WHO estimates that about 70% of the annual incidence of
4 - 5 million smear positive cases in the world occur in the Asia
continent.
4
Tuberculosis is a disease which afflicts at least six
million Asians every year, out of whom three million are
* Bagian dari laporan ("travel research report") yang telah disampaikan ke South
East Asia Medical Information Center (SEAMIC) Tokyo -- Jepang.
infectious; only one third are diagnosed and put on treatment
and another one third needlessly succumb to the disease. Even by
the year 2000, tuberculosis will still remain a major health
problem in Asia continent, because of the difficulties encoun-
tered by the countries in their development and the anticipated
doubling of population.
5
Lin made a survey on tuberculosis problem in East Asia and
the South Pacific area, and he found that the tuberculosis
mortality was very high - around 200 per 100,000 - right after
the war in almost all East Asian countries. The mortality rate
was declining; however, the tempo of its decline varied between
countries with fastest one seen in Japan.
4
According to Styblo's
estimate, the incidence rate of smear positive cases in the world
is highest in Africa, with 165 per 100,000 population, followed by
Asia with 110; the actual number of new cases is, however,
3 - 7 times greater in Asia than Africa because Asia's larger
population.
6
The annual risk of infection in most developing countries are
about 20-50 times higher than in technically advanced
countries. The risk of infection in Japan is about 0,1% with an
annual rate of decrease of 11%, and this is quite similar to that
of France.
7
In most European countries, the estimated annual
risk of infection is 1 to 3 per 1000, and is falling at the rate of 10%
Cermin Dunia Kedokteran No. 63, 1990
4
or more every year.
8
The lowest figure of 0,1 % was observed in
Netherland and Scandinavia.
7
The annual risk of infection in
many African countries is about 1.5 - 3%, and in South East
Asia region the annual risk is about 2% - corresponding to an
incidence of about 100 smear positive cases per 100,000
population.
9
INDONESIA
Tuberculosis ranks as the 4th leading cause of death in
Indonesia, and is also one of the ten leading morbidity causes,
according to Household Health Survey in 1986. In previous
survey (1980), tuberculosis also got the same position in the
ten leading causes of death.
10
Tuberculosis prevalence survey was done in 1979 - 1982,
in 15 provinces. The result (table 1) showed the variation of
prevalence in each province. The highest was 0.74% in East Nusa
Tenggara province and the lowest was in Bali province, 0.08%.
Another survey was done in Aceh province (1983) and found
a prevalence of 0.57% and in West Sumatra province (1984-1985)
with a prevalence 0.27%.
11
The result of the prevalence survey in
15 provinces (table 1) showed that the averange prevalence was
0.29%.
The National Health System ("Sistem Kesehatan Nasional")
aims to reduce the prevalence of smear positive tuberculosis
to 0.2% by the year of 2000.
12
Table 1. Prevalence of smear-positive and population in 15 provinces in Indo-
nesia
No. Province Population
Prevalence of
Year of
in 1982
Smear Positive Survey
1. Bali
2.555.300
0,08
1980
2. Central
Java
26.226.600
0,13
1979
3. West
Kalimantan
2.603.000
0,14
1980
4. Aceh
2.767.400
0,15
1981
5. DKI
Jakarta
7.038.100
0,16
1980
6. North
Sulawesi
2.215.300
0,30
1981
7. West
Java
28.946.600
0,31
1980
8. DI
Yogyakarta
2.813.300
0,31
1980
9. East
Java
30.078.800
0,34
1980
10. West
Sumatra
3.506.300
0,38
1980
11. South
Sumatra
4.944.300
0,42
1980
12. South
Sulawesi
6.278.200
0,45
1980
13. East
Kalimantan
1.362.800
0,52
1981
14. North
Sumatra
8.803.500
0,53
1980
15.
East Nusa Tenggara
2.846.400
0,74
1983
Total 133.039.900
0,29%
Indonesia 154.661.700
Source : Directorate General CDC and EH, Ministry of Health, Indonesia.
Table 2 presents a result of tuberculin test survey. The
survey was designed to calculate the annual tuberculosis infec-
tion rate and the annual reduction rate. This survey was done
in 10 districts in Indonesia every five years, starting in 1972.
Table 2. Prevalence of tuberculosis infection from the tuberculin test survey in
Indonesia (1972 - 1987) (11)
First survey
Second survey
Third survey
District
(Province)
Result
(year)
AIR Result
(year)
AIR ARR
Result
(year)
AIR ARR
Tangerang
36.25 5.2 26.44 3.5 7.8 18.50 2.4 7.3
(West Java)
(1972)
(1978)
(1983)
Pati
13,36
1.7 17.34 2.2 -5.3
13.72
1.7
5.0
(Central Java)
(1974)
(1979)
(1984)
OKI
28.90
3.9 28.06 3.8 0.5
27.05
3.6
1.1
(South Sumatera)
(1975)
(1980)
(1985)
Gowa
30.02
4.1 30.11 4.1 0.0
29.94
4.1
0.0
(South Sulawesi)
(1975)
(1980)
(1985)
Sambas
23.62 31.1 14.21 1.8 10.3
15.00
1.9
-1.1
(West Kalimantan)
(1976)
(1981)
(1986)
Padang
17.17
2.2 14.51 1.8 3.9
23.76
3.1
-11.5
(West Sumatera)
(1976)
(1981)
(1986)
H.S.T.
29.35
4.0 62.88 3.6 2.1
21.70
2.8
4.9
(South Kalimantan)
(1977)
(1982)
(1987)
Langkat 14.66
1.8 10.34 1.3 6.3
-
(North Sumatera)
(1978)
(1983)
Malang 7.66
0.9
5.33
0.6
7.8
-
-
-
(East Java)
(1979)
(1984)
S. Ulin
24.43
3.2
-
-
-
-
-
-
(Aceh) (1983)
.
Note : all number in %
-
AIR = annual infection rate
-
ARR = annual reduction rate
SINGAPORE
Tuberculosis was the most frequently notified communi-
cable disease in 1986. In 1987 tuberculosis was the 9th principal
causes of death with a rate of 7 per 100,000 population, and in
1987 tuberculosis was the cause of death in 1.4% of the total
death in Singapore.
13
There has been a steady decline of tuberculosis notification
over the years. In 1987, a total of 1616 new notification were
were received, giving a rate of 62 per 100,000 population.
The average annual decline in rate since 1959 was 5.7%.
Among the 1616 new cases notified, 1499 (93%) were pulmo-
nary tuberculosis, and among this 1499 new pulmonary tuber-
culosis cases, 52% were smear positive. The incidence of tuber-
culosis is highest in the older age group. In the 1987 new
notifications among Singaporeans, 31.1% of the pulmonary
tuberculosis patients were 60 years or older and 19.17% were
between 40 - 59 years old. About 70% of the new pulmonary
tuberculosis patients cases in 1987 were males. This predomi-
nance becomes more evident with the increasing age (table 4).
14
The prevalence rate of smear positive pulmonary tubercu-
losis in 1975 was 0.14%. The rate for new cases pulmonary
tuberculosis (smear positive plus smear negative) in 1959 was
335 per 100,000 population, and it has fallen to 57 per 100,000
Cermin Dunia Kedokteran No. 63, 1990 5
Population in 1987 (table 3).
14
Out of 1346 new pulmonary
tuberculosis cases in 1987, 1299 (96.5%) had bacteriological
examination done. 665 (49,4%) were bacillary positive cases and
634 (47.1%) were bacillary negative cases; 51.4% were positive
both on smear and culture and 46% on culture alone.
14
Table 3. New Cases of Tuberculosis. Singapore, 1959 1987.
N U M B E R
RATE
Per 100,000 population
Year
Total Pulmonary
Extrapulm
only
Dual
Condition Pulmonary
All
Forms
I
Percent,
change
in rate
1959 5666 5637
29
*
355 357
-
1960 5057 4985
72
*
303
307 -
11.0
1961 6299 6216
83
*
365
370 +20.5
1962 5773 5695
78
*
325
330 -
10.8
1963 4654 4555
99
*
254
259 -
21.5
1964 4532
4430
102
*
241
246
- 5.0
1965
4711
4541 170 *
241 250
+
1.6
1966
4163
3966 197 *
205 215
-
14.0
1967
3647
3434 213 261 174 184
-
14.4
1968
3764
3536 228 90 176 187
+
1.6
1969 3760
3471 289 115 170 184
-
1.6
1970
3292
3049 243 72 147 159
-
13.6
1971
3407
3195 212 91 151 161
+
1.3
1972 3109
2941
168
89
137
145
- 9.9
1973 3037
2824
213
85
129
139
- 4.1
1974
3451
3205 246 96 144 156
+
12.2
1975 3097
2917
180
86
129
130
- 11.5
1976 2813
2629
184
116
115
124
- 10.1
1977
2760
2583 177 81 111 120
-
3.2
1978
2964
2744 220 127 117 127
+
5.8
1979
2800
2604 196 124 109 119
-
6.3
1980
2710
2525 185 115 105 113
-
5.0
1981 2425 2232
193
119
91
99 -
12.4
1982 2179 1994
185
131
81
88 -
11.1
1983 2065
1878
187
148
75
83
- 5.7
1984 2143 1949
194
148
77
85 +
2.4
1985 1952 1781
171
121
70
76 -
10.6
1986 1760 1570
190
131
61
68 -
10.5
1987 1616
1499
117
145
57
62
- 8.8
Note : - Pulmonary tuberculosis refers to disease of the lungs only
- Extrapulmonary tuberculosis includes disease of the pleura, larynx, bron-
chial tree and all other sites except the lungs
- Cases with both pulmonary and extrapulmonary tuberculosis are included
in "Pulmonary" column
* Figures not available
In 1987 there were 177 death attributed to tuberculosis
(including deaths from late effects to the disease). Giving a rate of
6.8 per 100,000 population. For pulmonary tuberculosis, the
death rate in 1977 was 14,3 per 100,000 population and in
1987 it was 6.4 per 100,000 population.
14
(table 5)
Several treatment regimen used by Department of Tuber-
culosis Control (DTBC) Tan Tock Seng Hospital Singapore are :
- 6-month chemotherapy : 1 SHRZ/5 H3R3 ; 2 SHRZ/4 H3R3
2 HRZ/4 H3RE
2 SHRZ/4 RH; 2RHZ/4 RH
- 9-month chemotherapy : 2 EHR/7 RH
- 12-18 month chemotherapy (les commonly used) :
2 SEH/10 EH or 2 SEH/16 EH
2 SEH/10 H2S2 or 2 SEH/16 H2S2
The choice of regimen depends on patient's condition.
Table 4.. Tuberculosis Notifications by Age and Sex. Singapore,
1987
(Residents only)
14
New Cases
Pulmonary Pulmonary Pulmonary
Relapses Total Noti-
fications
Age
Group
M F M F
M F M F M F
0 - 9
1
3
3
2 4 5 0 0
4
5
10 - 19
49
38
3
3
52
41
2
1
54
42
20 - 29
121 101
4 12 125 113
8 6
133 119
30 - 39
111 60 8 12 119 72 13 5
132 77
40 - 49
131 41 2 14 133 55 19 5
152 60
50 - 59
210 48 4 8 214 56 61 9
275 65
60 +
329
103 8 9
337 112 99 25
436 137
All Ages
952 394 32 60 984
454 202 51 1186 505
Table 5. Tuberculosis death rate (per 100,000 population) including death from
late effects of tuberculosis 1977 - 1987 in Singapore
14
Year
Pulmonary
Extra Pulmonary All Forms
1977 14.3
0.4 14.7
1978 13.0
0.6
13.6
1979 13.3
0.9
14.0
1980 9.3
0.7 10.0
1981 8.1
0.9
9.0
1982 7.6
0.8
8.4
1983 8.1
0.8
9.0
1984 6.0
0.4
6.4
1985 6.5
0.4
6.9
1986 6.2
0.7
6.8
1987 6.4
0.4
6.8
BRUNEI
.
DARUSSALAM
In 1985 tuberculosis is 4th on the list of communicable
diseases in Brunei Darussalam, after chicken pox, measles and
diarrhoea) diseases. There were a total of 238 new tuberculosis
patients registered in 1985, of which 166 (69.75%) were male and
72 (30.25%) female. Out of this 238 tuberculosis cases, there
were 218 (91.60%) cases of pulmonary tuberculosis - 61 (27.98%)
male and 157 (72.11%) female. 52 (23.85%) of pulmonary
tuberculosis patients in 1985 were 60 years old or over and
another 161 patients (73.85%) were between 15 - 59 year old.
15
In 1987 there were 189 tuberculosis cases registered, of which
139 (73.54%) were Bruneian and 50 patients (26.46%) were Non
Bruneian residents (table 7)
16
The tuberculosis mortality for
Brunei Darussalam is 8.5/100,000, and the
"
lost cases
"
is 14%
(mainly consist of expatriate workers).
16
The attack rate of tuberculosis in 1985 was 0,82 per 1000
population in Brunei/Muara and Temburong districts, 0.57%
per 1000 population in Belait and 1.2 per 1000 in Tutong
district. In 1986 there were 84 bacillary positive cases for
226,000 population, giving a rate of 0.037%.
Cermin Dunia Kedokteran No. 63, 1990
6
Table 6. Tuberculosis by age and sex in Brunei Darussalam 1985
15
0--14
years old
15--59
years old
60
years & over
Pulmonary TB
M
F
3
2
112
49
42
10
Extra pulmonary TB
M
F
6
3
8
1
1
Miliary TB
M
F
-
-
1
-
-
Total
11 173
54
Table 7. Tuberculosis by sex and residential status 1983 -- 1987 in Brunei
Darussalam
16
Bruneian Non
Bruneian
Year
Male
Female
Male
Female
Total
1983
113 69
58 72 254
1984
93 66
74 17 250
1985
99 48
65 26 238
1986
93 51
48 20 212
1987
89 50
31 19 189
Total
771 (67.45%)
372 (32.55%)
1143
Table 8. Tuberculosis by bacteriological status and districts in Brunei Darus-
salam (1984 1986).
16
Brunei & Muara
and Temburong
Tutong Kuala
Belait
Total
Year
Pos (+) Neg (--) Pos (+) Neg (--) Pos (+) Neg (--) Pos (+) Neg (--)
1984
39 125 7 24 27 55 73 177
1985
68 177 3 24 19 15 90 148
1986
48 90
16 18 20 20 84 128
Treatment and control of tuberculosis are directly managed by
the specialist (in Chest Clinic and the supporting teams in
districts. The therapy regimen in the absence of hepatic or renal
dysfunction) are rifampicin, INH and pyrazinamide daily
.
super-
vised for 4 weeks, followed by rifampicin and NH bi-weekly
supervised for 9 months. If the patient is admitted to hospital
or is willing to attend daily, he/she should in addition have
streptomycin daily for four weeks.
PHILIPPINES
Tuberculosis was formerly ranked first among the ten leading
of death in the Philippines. In 1955 pneumonia replaced tuber-
culosis as the number-one causes of death, and in 1984 tuber-
culosis slipped to number three. From 1940 -- 1960, the rate
of tuberculosis mortality declined by 3.5% annually, but from
1960 1980 the reduction rate of tuberculosis mortality
was just 1.5% annually. " In 1985 tuberculosis (all form) ranks
fifth in the ten leading causes of morbidity.
18
The Tuberculosis National Prevalence Survey was done in
1981 1983. In persons aged 10 years or more, the estimated
prevalence of bacteriologically confirmed tuberculosis is 1.25%;
the prevalence of smear positive cases is 0.95% Since bacterio-
logically positive cases are rare among those below 10 years of
age, the corresponding prevalence rates in the population of all
ages would be 0.86% and 0.66% respectively. In general, male had
a substantially higher prevalence than female -1.62% vs 0.93%
for culture-positive cases and 1.26% vs 0.69% for smear-positive
cases. The estimated number of tuberculosis cases in each level
in the Philippines is shown in table 9. Another finding of this
National Prevalence Survey was the sociological findings, which
showed that 28% of person 20 years or older had experienced
symptoms suggestive of tuberculosis. Of these, 17% were classi-
fied as symptomatic TB. Actions taking for tuberculosis patients
is also quite high, 64.9% among symptomatic TB are under
treament. Of these, 39% resort to self medication, 26% go to
private practitioners, 22% attend health centers, 9% go to hospi-
tals and the remaining 4% take other action.
17
Table 9. Estimated Number of TB Cases by Bacteriology, Radiography and
Number Infected with Tubercle Bacilli, by Tuberculin Testing for 1987,
Based on Average Population of Each Level.
The use of short course chemotherapy in the NTP was adopted
nationwide on 1986. The initial phase of the short course
chemotherapy consists of two month daily administration of
Procedure
.
Philippines
Pop-57,
356, 042
Province
Pop-
500,000
Municipality
Pop-
25.000
Barangay
Pop-
5.000
A. Bacteriological Examination
1. Culture positive TB
cases (0.86%)
493,261 4,300
215
43
2. Sputum positive TB
cases (0.66%)
378,549 3,200
165 33
B. X-Ray Examination
1. Total with radiographic
abnormalities (2.90%) 1,663,325 14,500
725
145
2. Minimal cases (1.72%)
986,523
8,600
430
86
3. Moderately advanced
cases without cavity 0.69%)
395,757 3,450
172 34
4. Moderately advanced
cases with cavity (0.14%)
80,299 700
35 7
5. Far advanced cases
without cavitary (0.14%)
80,299 700
35 7
6. Far advanced cases
with cavitary (0.14%)
80,299 700
35 7
C. Tuberculin Testing
1. TB infection among
general population (32.4%) 18,583,357 163,500
8,175
1,635
D. Symptom Inquiry
1. TB symptomatics (8%) 4,588,483 40,00
2,000
400
Cermin Dunia Kedokteran No. 63, 1990 7
INH, Pyrazinamide and Rifampicin, and the continuation phase
consists of four months of daily administration of INH and
Rifampicin. The standard course chemotherapy have two regi-
mens, Regimen A is INH daily together with Streptomycin
daily for 4 week and then twice weekly till the end of 12 months.
Regimen B consists of INH daily and Streptomycin twice weekly
fully supervised at a treatment center."
CONCLUSION
Tuberculosis is still a health problem in South East Asia
region. The epidemiological situation are different from country
to country.
The prevalence of smear positive cases in the Philippines were
0.66%, which means 378,549 people in 1987.
In Indonesia, the prevalence of smear positive, cases were
0.29%, which corresponds to a half of million people. Tuber-
culosis ranks fourth in ten leading causes of death in Indonesia,
according to the Household Health Survey 1986.
The epidemiological situation in Singapore and Brunei are
rather different. In Singapore, there were 1499 notified pulmo-
nary TB cases for the year of 1987. The prevalence rate of
smear positive cases in Singapore for 1975 was 0.14%. In Brunei,
there were 218 new pulmonary tuberculosis patients registered in
1985. In 1986, there were 84 bacillary positive cases for
226,000 population, giving a rate of 0.037%.
In the Philippines (1984), tuberculosis was the third leading
causes of death. Tuberculosis, bronchitis-emphysema and
asthma ranks 10th among ten leading causes of death in Singa-
pore in 1987. The tuberculosis mortality rate for Brunei Dams-
salam is 8.5/100,000. Tuberculosis is still a killer and there
must be a continuous fight against it.
To solve the tuberculosis problem, there must be some kind
of cooperation or collaboration between countries in the South
East Asia region. This collaboration would be very beneficial
for sharing and exchange the experiences and knowledge.
There are now more cases of tuberculosis in the world than
ever before because in most densely populated areas the pre-
valence has not decreased. On the other hand, we have the
knowledge and means to cure, to relieve human suffering and
to break the chain of disease transmission; global fight against
tuberculosis is a must to reach a goal of eradication of tuber-
culosis problem in the world.
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