Indonesia is gearing up to welcome thousands of delegates to the largest lung health gathering, the Union World Conference of Lung Health 2024, in Nusa Dua, Bali from Nov 12 through Nov 16 this year.
Dr Guy Marks, president of the International Union Against Tuberculosis and Lung Disease (the Union), said: “Last year (2023) was the first time we were able to hold the Union World Conference on Lung Health in person since the COVID-19 pandemic (in Paris), so it was only right to return to the Union’s birthplace in Paris, France.”
For more than 100 years, the Union World Conference on Lung Health has brought together global experts on lung health, presenting the latest scientific research in all aspects of lung health including all aspects of TB prevention, diagnosis and treatments.
“This year (2024), we wanted to hold the Union Conference closer to the affected community, in a country with a strong ambition to end TB and the infrastructure to host such an international gathering. Indonesia matched these criteria perfectly, so we are delighted to be in Bali this year,” added Marks.
This year’s conference is expected to present a large variety of groundbreaking science, cutting-edge innovations on lung diseases as well as community engagement.
Representatives of the affected community and civil society groups will come together to share experiences and develop solutions on issues surrounding lung diseases in an event called Community Connect, an open access where the voice of the affected community echoes to the world.
For Indonesia, the conference might serve as an important showcase of the country’s commitment, achievements as well as challenges in its efforts to end TB in 2030.
For Indonesia, the conference might serve as an important showcase of the country’s commitment, achievements as well as challenges in its efforts to end TB in 2030.
Indonesia has an ambitious target to end TB by 2030, in line with the Sustainable Development Goals (SDGs) set by the United Nations. To achieve this target, several important steps are being taken. Firstly, Active Case Finding (ACF) of TB is a major focus despite the challenges that they are facing in the implementation, locally or in national scope.
Political Commitment
Under the current President Joko (Jokowi) Widodo, the Indonesian government has shown a strong commitment in TB elimination by 2030 by the issuance of Presidential Decree No. 67/2021, which requires multi-sector collaboration involving 17 ministries including health Ministry, Finance Ministry, Home Affairs Ministry, Research and Technology Ministry and Coordinating Minister for Human Development and Culture.
Under the Presidential Decree, the governors and mayors will have to prioritize and take the lead on TB elimination in their jurisdictions.
To show its commitment, Indonesia had doubled its domestic funding for TB from US$109 million in 2019 to $155m in 2020, right before the outbreak of COVID-19 pandemic.
In 2022, funding for TB reached US$172 million from domestic (44 percent) and international sources (56 percent).
The World Bank data stated that the economic burden of TB in Indonesia is substantial, estimated that the overall annual cost of TB in the country to be US$6.9 billion annually.
Indonesia also participated in the United Nations General Assembly High Level Meeting (UNHLM) on TB in 2018 and 2030 and contributed to its Political Declaration (2018) and its Renewal Commitment (2030).
Indonesia has also been actively taking part in global clinical trials for TB vaccines, TB diagnostic studies, and operational research for TB treatment, all for accelerating the end TB target achievement by 2030.
Erlina Burhan, professor of respiratory medicine at University of Indonesia, said that TB elimination has always been part of the priority health issues, however, challenges still arise from the uneven distribution of over 276 million people with cultural and traditional diversity, natural condition, and the two-layer decentralized governance structure.
“Despite significant efforts to control this infectious disease, we still face several crucial challenges. Several factors contribute to these situations,” explained Erlina, who is also a Board member of the Union.
Reaching the unreached
Indonesia, as an archipelago with a vast geographical area of 17,000 islands and limited healthcare facilities in far-flung areas, presents a unique challenge in reaching out to TB patients.
“The challenges are limited basic healthcare facilities in inaccessible areas equipped with inefficient TB diagnostic tools and insufficient budget allocation for TB program in these areas. This results that TB remains one of the top causes of death in the country,” she noted.
Indonesia saw 1,060,000 of TB Incidence in 2022 or 385 persons per 100,000 populations, making it as the world second country with the highest TB burden, while TB mortality rate is 52 per 100,000 populations. In 2022, Indonesia saw 134,000 TB deaths.
HIV-positive TB incidence was 24,000; drug-resistant TB incidence was 31,000 persons.
The majority of TB cases in Indonesia were attributable to five risk factors namely smoking, undernourishment, HIV, diabetes and alcohol use disorders.
Beyond Health Issues
However, eliminating TB goes beyond just medical and public health efforts; it requires a holistic approach encompassing social, political, cultural, economic, and environmental conditions.
Malnutrition, housing, population density, and limited access to sanitation and health care facilities can also increase the risk of TB, she added.
These socioeconomic factors should be addressed by the participation of non-medical government and private institutions, the roles of which can be said either unexplored or neglected.
“To make things worse, the effects of socioeconomic factors are critical. Stigma and discrimination against TB patients still hamper the progress of TB eradication due to its effect on patients’ willingness to go to a doctor, denial of TB diagnosis, avoidance of starting therapy, and compliance with the therapy until its completion,” Erlina explained.
Early detection is crucial to break the chain of TB transmission. As important as active case findings, the National TB Program is also on its way to implementing a shorter regimen for TB treatment by initiating operational research for four-months of drug-susceptible treatment.
If the results are great and effective, the regimen will be used nationally and hopefully will increase treatment adherence in patients. Management of drug-resistant TB is also a serious concern. Indonesia has a specific program to address drug-resistant TB, which involves longer, and more complex treatment compared to regular TB.
“In addition, raising public awareness through health campaigns and education is crucial. The public needs to understand TB symptoms, the importance of completing treatment, and ways to prevent TB transmission,” she explained.
India-lesson learned
Tjandra Yoga Aditama, the Indonesian Lung Doctors Association (PDPI) honorary council chairman, stated that Indonesia could learn from India’s current achievements in reducing the mortality rate of TB.
India TB Report 2024, released last April, showed a significant decrease in the country’s TB death rates from 28 per 100,000 in 2015 to 23 per 100,000 populations in 2022. India also saw decrease in TB deaths from 494,000 in 2021 to 331,000 in 2022.
Tjandra, a medical professor at the University of Indonesia, added that India is the first largest contributor of TB cases in the world, but its population is 1.3 billion people, while Indonesia is 276 million. “One of the most striking achievements is treating 95 percent of its TB patients by 2023 both in public health facilities and private-owned healthcares and hospitals.
Integrating five risk factors including malnutrition, HIV, diabetes, alcohol and smoking into TB treatments is also key to the country’s successful effort,” added Tjandra, formerly Director of Infectious Diseases at WHO Southeast Asia.
High Burden Countries
It may seem perfect to hold the Union World Conference on Lung Health in Bali, Indonesia this year, as the world’s second highest TB burden country.
In a recent webinar organized by CNS, Marks stated: “TB must be treated as a public health problem, not merely an individual care issue.”
He also added that: “We must be brave and recognize that the current strategy to end TB in high burden countries is not achieving the result we hope for. We need to change our approach if we are to win the fight against this infectious disease.”
Marks is referring to the much-required paradigm shift in the way we find TB: national TB surveillance surveys in countries like India has proven that almost half of the people with active TB disease are asymptomatic (and found only when screened with x-rays). Instead of waiting for people to develop TB symptoms and get sick (by when the disease is advanced and has spread to many more people), we need to go out in the communities in high-burden settings and screen everyone (regardless of TB symptoms) – with WHO recommended tools such as ultraportable, handheld and artificial intelligence-backed x-rays, and link all those with TB to care pathway.
By doing so, high burden places in countries like Vietnam has brought down TB rates by over 70% in a period of 4 years (without which TB rate decline was around 1-2% a year). Finding all TB is a critical entry-gate to TB care pathway and breaking the chain of infection transmission.
Governments of high TB burden nations must not delay in finding all TB, treating all of them with effective and latest treatment regimens and preventing the spread of infection. Deploying WHO recommended point-of-care tools such as battery operated, artificial intelligence-backed ultraportable and handheld x-rays for TB screening, battery operated, laboratory independent and decentralized molecular tests like Truenat, must be leveraged to reach the unreached with best of TB services.
WHO Global TB Report 2023 reveals that TB caused an estimated 1.3 million deaths in 2022. Worldwide, an estimated 10.6 million people developed TB in 2022, up from the best estimates of 10.3 million in 2021. Geographically, in 2022, most people who developed TB were in Southeast Asia region (46 percent), Africa (23 percent) and the Western Pacific (18 percent).
Thirty high TB burden countries accounted for 87 percent of the world’s TB cases in 2022, and two-thirds of the global total was in eight countries: India (27 percent), Indonesia (10 percent), China (7 percent), the Philippines (7 percent), Pakistan (5.7 percent), Nigeria (4.5 percent), Bangladesh (3.6 percent) and the Democratic Republic of Congo (3 percent).
Governments of high TB burden nations must not delay in finding all TB, treating all of them with effective and latest treatment regimens and preventing the spread of infection. Deploying WHO recommended point-of-care tools such as battery operated, artificial intelligence-backed ultraportable and handheld x-rays for TB screening, battery operated, laboratory independent and decentralized molecular tests like Truenat, must be leveraged to reach the unreached with best of TB services.
WHO Global TB Report 2023 reveals that TB caused an estimated 1.3 million deaths in 2022. Worldwide, an estimated 10.6 million people developed TB in 2022, up from the best estimates of 10.3 million in 2021. Geographically, in 2022, most people who developed TB were in Southeast Asia region (46 percent), Africa (23 percent) and the Western Pacific (18 percent).
Thirty high TB burden countries accounted for 87 percent of the world’s TB cases in 2022, and two-thirds of the global total was in eight countries: India (27 percent), Indonesia (10 percent), China (7 percent), the Philippines (7 percent), Pakistan (5.7 percent), Nigeria (4.5 percent), Bangladesh (3.6 percent) and the Democratic Republic of Congo (3 percent).
In 2022, 55 percent of people who developed TB were men; 33 percent were women and 12 percent were children.
Indeed, there are magic formula and strategies to end TB at the global level, many of them may be perfect for countries in the Global North, yet it may not be suitable and applicable in the Global South hemisphere, where high burden countries are located.
It is highly expected that the upcoming Union World Conference on Lung Health in Bali will provide solutions to these lingering problems to end TB by 2030.
Bali, Indonesia
Rita Widiadana is a former Editor of The Jakarta Post (Indonesia) and Country Director of Consortium of Press Freedom (Indonesia). She is also on the board of Asia Pacific Media Alliance for Health and Development (APCAT Media) and Global Antimicrobial Resistance Media Alliance (GAMA). Follow her on Twitter @RitawidiadanaW
