Quality Tuberculosis Care in Indonesia: Using Patient Pathway Analysis to Optimize Public-Private Collaboration.

Background: Tuberculosis (TB) is the fourth leading cause of death in Indonesia. In 2015, the World Health Organization estimated that nearly two-thirds of the TB patients in Indonesia had not been notified, and the status of their care remained unknown. As such, Indonesia is home to nearly 20% of the world's "missing" TB patients. Understanding where patients go for care may enable strategic planning of services to better reach them. Methods: A patient pathway analysis (PPA) was conducted to assess the alignment between patient care seeking and the availability of TB diagnostic and treatment services at the national and subnational level in Indonesia. Results: The PPA results revealed that only 20% of patients encountered diagnostic capacity at the location where they first sought care. Most initial care seeking occurred in the private sector and case notification lagged behind diagnostic confirmation in the public sector. Conclusions: The PPA results emphasize the role that the private sector plays in TB patient care seeking and suggested a need for differentiated approaches, by province, to respond to variances in care-seeking patterns and the capacities of public and private providers.

The prevalence of sexually transmitted infections and their association with knowledge, attitudes, and practice in male street children in Indonesia.

BACKGROUND: Street children's level of knowledge, attitudes, and practice (KAP) regarding sexually transmitted infections (STIs) and HIV-related diseases remains a challenge since it is difficult to reach all key populations. This study aims to provide an overview of the findings of STI cases and their association with the KAP of street children in Jakarta and Banten. METHODS: We conducted a cross-sectional study on 259 male street children (aged 10 -21 years old). We collected the data through questionnaire interviews, history taking, physical examination, and specimen collection for STI and HIV testing. RESULTS: 5.8% (n = 15) STI cases were discovered, consisting of Hepatitis B (n = 6), Hepatitis C (n = 1), HIV (n = 2), Chlamydia (n = 3), Syphilis (n = 1), and Gonorrhea (n = 1). Buskers (44.4%) and other occupations like helping parents sell their wares, parking lot attendants, shoe shiners, or gathering (44.8%) dominated the sociodemographic characteristics. Condomless sex predominated risky sexual behavior, despite some subjects already having good knowledge. CONCLUSION: Sociodemographic characteristics and the KAP of street children in Indonesia are varied. The association between the KAP level and STI cases in street children is challenging to describe. Further studies covering more areas in Indonesia are required.

Serum iron levels in tuberculosis patients and household contacts and its association with natural resistance-associated macrophage protein 1 polymorphism and expression.

BACKGROUND: Iron deficiency can impair immune function, increasing tuberculosis (TB) susceptibility and severity. The research aimed to investigate iron deficiency anemia in TB patients and household contacts and its association with natural resistance-associated macrophage protein 1 (NRAMP1) polymorphism and expression. METHODS: The levels of iron, ferritin, and transferrin were measured in the serum by ELISA (Enzyme-Linked Immunosorbent Assay). NRAMP1 polymorphisms were determined by polymerase chain reaction (PCR) and sequencing. NRAMP1 gene expression was measured by real-time PCR. Interferon-gamma release assay (IGRA) checked on household contacts to screen household contacts with positive IGRA as the control. RESULTS: This study involved 35 TB cases and 35 TB contacts. The results showed that the serum Fe levels were found to be lower in the TB case group (median 149.6 µmol/L) than in the positive IGRA household contacts group (median 628.53 µmol/L) with a p-value <0.001. Meanwhile, ferritin levels in TB cases tended to be higher, in contrast to transferrin, which was found to tend to be lower in TB cases than household contacts but did not show a significant difference. This study found no association between the polymorphism of exon 15 D543 and active TB. However, NRAMP1 gene expression was lower in TB cases than in positive IGRA household contacts (p = 0.011). Besides, there was a positive correlation between NRAMP1 gene expression and serum Fe levels (r = 0.367, p = 0.006). TB was associated with decreased NRAMP1 gene expression (OR 0.086 95% CI 0.02-0.366, p = 0.001). Besides, TB was associated with low Fe levels (OR 0.533 95% CI 0.453-0.629, p < 0.001). CONCLUSION: Comparing the TB case to the household contacts group, decreased serum Fe levels were discovered in the TB case group. This study also shows a correlation of NRAMP1 gene expression to Fe levels in TB patients and household contacts and describes that TB may lead to decreased Fe levels by downregulating NRAMP1 expression.

Whole-of-society approach for influenza pandemic epicenter Containment exercise in Indonesia.

BACKGROUND: Since 2003, 200 cases of bird flu (H5N1) cases have been reported with 168 death (case fatality rate: 84%) in Indonesia. Pandemics are unpredictable, but the threat is imminent. Therefore, pandemic preparedness, which includes full simulation exercises, is a key to reduce this threat. Responding to the challenges, Ministry of Health (MoH) Indonesia adopted WHO pandemic risk management guideline, developed contingency plan and conducted full scale epicenter influenza pandemic simulation. METHOD: The exercise outlines the Government of Indonesia operational plans for Avian Influenza (AI) control from the detection of AI cases (from poultry to human transmission) and containment of human to human transmission of novel influenza virus in influenza pandemic epicenter at Setu village South Tangerang. The simulation covers multiple locations in community, hospitals, point of entry and live bird market. 25 evaluators and around 800 observers involved in the exercise. RESULTS: The full scale pandemic epicenter containment exercise has demonstrated Indonesia capacity in whole of society approach pandemic risk management in the overall national emergency response framework, covering command and coordination, animal health response surveillance, medical response, laboratory, risk communication, perimeter control, pharmaceutical interventions, non-pharmaceutical interventions and civil-military interoperability. It is served as a momentum to improve multisector commitment on pandemic preparedness. The outcome of this exercise has contributed to identification of gaps that require further strengthening of IHR core capacities in the country to reduce the threat of the next influenza pandemic. CONCLUSION: There is also a critical need for more evidence-based strategies and policy formulation to strengthen pandemic preparedness.

Initial success from a public health approach to hepatitis C testing, treatment and cure in seven countries: the road to elimination.

With political will, modest financial investment and effective technical assistance, public sector hepatitis C virus (HCV) programmes can be established in low- and middle-income countries as a first step towards elimination. Seven countries, with support from the Clinton Health Access Initiative (CHAI) and partners, have expanded access to HCV treatment by combining programme simplification with market shaping to reduce commodity prices. CHAI has supported a multipronged approach to HCV programme launch in Cambodia, India, Indonesia, Myanmar, Nigeria, Rwanda and Vietnam including pricing negotiations with suppliers, policy development, fast-track registrations of quality-assured generics, financing advocacy and strengthened service delivery. Governments are leading programme implementation, leveraging HIV programme infrastructure/financing and focusing on higher-HCV prevalence populations like people living with HIV, people who inject drugs and prisoners. This manuscript aims to describe programme structure and strategies, highlight current commodity costs and outline testing and treatment volumes across these countries. Across countries, commodity costs have fallen from >US$100 per diagnostic test and US$750-US$900 per 12-week pan-genotypic direct-acting antiviral regimen to as low as US$80 per-cure commodity package, including WHO-prequalified generic drugs (sofosbuvir + daclatasvir). As of December 2019, 5900+ healthcare workers were trained, 2 209 209 patients were screened, and 120 522 patients initiated treatment. The cure (SVR12) rate was >90%, including at lower-tier facilities. Programmes are successfully implementing simplified, decentralised public health approaches. Combined with political will and affordable pricing, these efforts can translate into commitments to achieve global targets. However, to achieve elimination, additional investment in scale-up is required.