Highest level of political commitment needed to end TB by 2030

(first published in The Jakarta Post, Indonesia on 25 October 2019)

Indonesia has one of the world’s highest rates of tuberculosis (TB) infections. Rita Widiadana and Shobha Shukla spoke with Erlina Burhan, head of directly observed treatment short course (TB DOTS) and multi-drug-resistant TB at Persahabatan Hospital, East Jakarta, for The Jakarta Post. Erlina is also a board member of the International Union Against Tuberculosis and Lung Disease, which will hold its 50th conference in Hyderabad, India, on Oct. 30-Nov. 2. The following are excerpts from the interview.

What is Indonesia’s major target in eliminating TB by 2030?

Indonesia is one of the United Nations (UN) member countries that have committed to upholding the 2018 Political Declaration of the UN high-level meeting on tuberculosis that includes treating 40 million patients with TB and 30 million people with latent TB infection (LTBI) globally by 2022. A person with LTBI does not have TB symptoms and cannot spread the bacteria to others, but can develop active TB. The target for Indonesia is to treat 1.56 million people with LTBI by 2020.

What does the country have to do to eliminate TB by 2030?

Indonesia is a high-burden TB country, ranking third in the world after India and China. The incidence is around 845,000 cases per year, meaning there are many contacts with TB patients. An estimated 85 million of the population is already infected with LTBI.

(TB remains among Indonesia’s top-four causes of death with 300 people dying of TB daily; a study estimates the economic burden related to treated and untreated cases reach US$6.9 billion).

But it is difficult to treat 85 million people. So, the government is prioritizing high-risk groups such as children under 5 and people living with HIV for preventive treatment. But we need to [...] target other risk groups to be screened and treated for LTBI

What strategies, treatments and methods are being implemented in Indonesia?

If Indonesia wants to eliminate TB by 2030, [...] we must [find] people with LTBI -- through contact investigation, screening at the community level, in high-risk groups -- and administer preventive TB treatment.

We are still struggling in curing active TB, but now our National Tuberculosis Program is shifting the focus onto children under 5 and also treating latent TB among HIV-infected patients. [...] Treating drug-resistant TB is also formidable. So, we have to prevent drug-sensitive TB patients from developing drug resistance by treating them until cured. [And] we must reduce the number of people with drug-sensitive TB. If we do not want to have the problem of drug-susceptible TB, we will have to prevent LTBI from developing into active TB by providing preventive treatment.

What is the treatment for children with TB in Indonesia?

Coverage of preventive TB therapy for children under 5 is only 13 percent, which is very low. We must increase the coverage of preventive TB therapy among children. Moreover, contact investigation/tracing is not in place properly. We also see children with drug-resistant TB, at least one every month in our hospital. We have a 9-month-old baby with multi-drug-resistant TB, who perhaps got it from the grandfather who had TB.

How serious is the connection between TB infection and tobacco use in Indonesia?

Cigarette smoking reduces the respiratory defense mechanism and impairs the mucociliary system (a self-clearing mechanism of the airways of the respiratory system, to remove inhaled particles including pathogens from lungs).

Almost 70 percent of adult males are smokers. Many of my TB patients were active smokers. They only stopped smoking after getting diagnosed with TB. Some still continue smoking.

(The Southeast Asia Tobacco Control Alliance reports Indonesia has 65.19 million active smokers, 34 percent of the population. Passive smokers amount to 97 million people)

The cigarette industry here is very strong. They are seen as a big source of revenue for the government as they pay high taxes (Indonesia's cigarette industry produces around 300 billion cigarettes every year).

The expenditure on treating diseases caused by smoking is many times higher than the revenue generated by cigarette sales. There needs to be more awareness and education of people on the connection between tobacco and TB. [...]

There is also a close connection between TB and non-communicable diseases. In my hospital, 30 percent of our multi-drug-resistant TB patients and 20-30 percent of the patients with drug-sensitive TB also have diabetes [which] affects the immune system. A person with diabetes is four times more prone to TB compared to one without diabetes.

The same is true of cancer. Around 70 percent of the lung cancer patients in my hospital have been active smokers. Also 15 percent of the lung cancer patients in this hospital who underwent chemotherapy have latent TB infection.

With such gigantic challenges, what steps should be taken?

The first crucial step is to increase awareness and engagement at all political levels-from the topmost level--the President. If the President says, "Find and treat TB everywhere in the country”, then it will happen immediately. Shockingly, some lawmakers do not even know that TB still exists in Indonesia. They say, "Oh, do we still have TB, are you sure?” The problem with Indonesia is that TB is the concern of only the medical fraternity and the Health Ministry. Actually, TB is a cross-cutting issue that should be the concern of other ministries and institutions, including provincial and regency governments.

We have to educate people at all levels -- the patients, their families, the peer groups [...]. TB is transmitted but can be cured if treated properly [and] timely. People still [...] do not consider coughing a serious problem until they are coughing sputum mixed with blood. [...] A persistent cough requires medical attention. [...] TB is preventable, and timely diagnosis and treatment are important. We also must pay attention to social enablers of TB such as nutrition, sanitation and infection control. Most of all, TB should be viewed as everyone's business.

Shobha Shukla is executive director and managing editor of India-based Citizen News Service. Shukla and Rita Widiadana are cofounding members of the Asia-Pacific Media Alliance for Ending Tobacco, TB and Preventing Non-communicable diseases.

(first published in The Jakarta Post, Indonesia on 25 October 2019)