A health worker conducts a chest X-ray scan at Tangerang City General Hospital in Banten, on March 21, 2023. - Antara
JAKARTA (The Jakarta Post) The government is planning to revive sanatoriums as a tool to eradicate tuberculosis (TB). But experts are concerned the strategy will not help in the fight against the infectious disease.
President Joko 'Jokowi' Widodo recently instructed the Health Ministry to reestablish sanatoriums as part of the government’s strategy to curb increasing TB cases in the country. The ministry recorded 354 cases of TB and 34 deaths from the disease per 100,000 population.
The government aims to reduce the number to 65 cases and six deaths per 100,000 population by 2030.
Indonesia is the second-highest contributor to global TB cases in the world after India, according to the 2022 Global TB Report issued by the World Health Organization (WHO).
The condition was worsened by the Covid-19 pandemic, leading to a 17-per cent increase of cases: from 824,000 in 2020 to 969,000 in 2022.
The South-East Asian country is also among the top four contributors of global TB deaths.
The infectious disease, usually caused by Mycobacterium tuberculosis bacteria, remains among the top four leading causes of mortality in Indonesia at 93,000 deaths per year or around 11 per hour.
Sanatoriums would limit the risk of disease transmission to healthy family members, while health workers could monitor the patients to make sure they stayed on their medication, said Health Minister Budi Gunadi Sadikin.
People with tuberculosis need to undergo a six-month medication regimen without missing a single dose to be fully cured. The ministry was still formulating details on the sanatorium programme, including the length of the quarantine and whether the programme would be made mandatory for people with TB, said ministry spokesperson Siti Nadia Tarmizi.
“So far, we only plan to quarantine patients with poor adherence to the treatment regimen or those who live with children,” Siti told The Jakarta Post on Tuesday (Aug 1).
Patients treated in a facility, she added, would also receive healthy and nutritious meals to support their recovery process. Sanatoriums would also provide easier access to medication for patients living far from healthcare facilities.
Malnutrition is often blamed as the main cause of the TB spread in the country.
Most Indonesians with the disease come from low-income families living in poor and heavily dense neighbourhoods that lack basic services, including clean running water.
Stigmatising patients
Health experts, however, have raised concerns that the plan to reestablish sanatoriums would be a setback in the country’s progress in dealing with tuberculosis.
“The strategy is clearly not based on the latest scientific findings,” said epidemiologist Dicky Budiman from Griffith University in Australia.
“Sanatoriums were popular in the 1900s because we didn’t have effective medication back then.”
Most sanatoriums across the globe were closed in the mid-1900s when scientists discovered antibiotics that could effectively treat TB.
Some sanatoriums in Indonesia were later converted into hospitals, such as Dr M. Goenawan Partowidigdo lung hospital in Cisarua, Bogor regency, West Java.
Putting tuberculosis patients in sanatoriums, he added, would only push stigma against them. The discrimination could negatively affect their mental health and quality of life.
Some studies also found that patients treated at sanatoriums faced a higher risk of cross-infection with other diseases, including drug-resistant tuberculosis, which is more fatal and can cause more severe symptoms.
Dicky suggested that outpatient treatment was far more cost-effective than inpatient care with the same efficacy in treating tuberculosis.
Should the government decide to march on with the plan, they should carefully pick the names of sanatoriums to prevent further stigma against the patients, suggested Windhu Purnomo, an epidemiologist from Airlangga University in Surabaya, East Java.
The government, he added, should also make sanatoriums optional for TB patients.
“They shouldn’t stay at the facilities for long, a month at most, so they could learn good habits to prevent transmissions and stay on their medication.”
Detection and vaccines
Aside from the sanatorium idea, the government is planning to ramp up TB detection as part of the campaign to eradicate the infectious disease. Last year, health authorities tracked down more than 700,000 TB cases out of an estimated 969,000 total cases in Indonesia, or a 74 per ent detection rate, the highest in the past 27 years.
The government aims to detect 90 per cent of all estimated cases by 2024. Experts deem TB screening an important first step in curing the disease.
In some cases, people with tuberculosis do not show any symptoms, putting healthy family members around them at risk of contracting the disease.
Early detection is also important so that patients can receive treatment promptly. The government is also putting hope in three new TB vaccine candidates currently under development.
One of them is called M72/AS01E developed by London-based drug firm GSK. This vaccine candidate contains the M72 recombinant fusion protein, which is derived from two TB bacteria antigens combined with the GSK proprietary Adjuvant System AS01E.
The M72/AS01E is slated for its phase III clinical trial after receiving funding from the Wellcome Trust and the Bill & Melinda Gates Foundation in late June.
The Health Ministry has sent a request to the two philanthropic organizations to appoint Indonesia as a location for the clinical trial. The ministry would work with the University of Indonesia, Padjadjaran University and the Food and Drug Monitoring Agency (BPOM) should the country be picked for the trial.
Until today, the only vaccine available worldwide is the Bacillus Calmette-Guérin (BCG), named after its founders Albert Calmette and Camille Guérin.
With its first medical use in 1921, the vaccine is on the WHO’s List of Essential Medicines as well as Indonesia’s mandatory childhood vaccination list.
While the BCG vaccine offers effective protection against TB for children, it provides limited help for adults.
A study published last year in The Lancet Global Health suggested that protection from the BCG vaccine may begin to wane as children get older, although a booster of the same vaccine on adults only has limited efficacy. The authors of the study suggest new vaccines are necessary, especially in countries with a high risk of tuberculosis, including South Africa, Vietnam and Indonesia
