Hospital DOTS linkage in Indonesia: a model for DOTS expansion into government and private hospitals.

BACKGROUND: To accelerate DOTS expansion, the hospital sector and specialized chest clinics must be engaged. OBJECTIVE: To develop a model for public-private partnership through DOTS expansion into public and private hospitals in Indonesia. DESIGN: Model development included gaining commitment from stakeholders, stepwise training of hospital staff, and developing unified networks for case management, patient referral, laboratory quality assurance, supervision and evaluation. RESULTS: The number of notified tuberculosis (TB) cases (all forms and new smear-positive) increased dramatically from baseline. Together, hospitals and chest clinics accounted for a significant proportion of the total cases notified by the province (51% of total TB cases and 56% of new smear-positive cases in 2004). Compared to health centers and chest clinics, hospitals reported lower cure and success rates. Despite the option for referral to health centers, the majority of patients diagnosed in hospitals and chest clinics in 2002-2004 opted to be fully managed by the diagnosing facility. CONCLUSION: The roles and strengths of hospitals differ with regard to health centers, providing a rational basis for linkage of these health service components. In Yogyakarta, linkage became effective only after establishing a stakeholder-based provincial coordinating (DOTS) committee as the recognized interface between the National Tuberculosis Programme and various providers.

Study on the detection of leprosy reactions and the effect of prednisone on various nerves, Indonesia.

This paper presents a retrospective study on the detection of the treatment of leprosy reactions in a field situation, and the effect of prednisone on the various affected nerves. Two patient cohorts were analysed. The leprosy control programme in the testing area is not backed up by a specialized referral leprosy hospital, but patients are treated on an ambulatory basis at peripheral health centres by trained multipurpose health workers supervised by the health centre doctors. For operational purposes the guidelines and procedures for reaction management in the field were adjusted and partially simplified. In both studies it appeared that the time of the occurrence of severe reactions was the same: 80% or more of the severe reactions occurred in the first year of treatment, the majority in the first few months after the start of the multidrug (MDT) treatment. One third of all reaction patients suffered from a silent neuritis. Well-instructed fieldworkers proved to be competent in detecting and treating leprosy reactions. Treatment of severe reactions with prednisone in the field situation can preserve or considerably improve the functions of the affected nerves. It is interesting that often the motor function of a nerve was found to be impaired without any loss in sensibility, which was tested using the ballpoint pen method.

PIP: A retrospective study of two patient cohorts in Central Sulawesi, Indonesia, analyzed the detection of the treatment of leprosy reactions in a field situation and the effect of prednisone on the affected nerves. In Indonesia, leprosy patients are treated on an outpatient basis at peripheral health centers by trained multipurpose health workers supervised by the health center doctor. The first cohort included 69 patients with severe reactions (125 affected nerves) and the second was comprised of 85 patients with severe reactions (180 affected nerves). Both groups were treated with the minimum standard dose of prednisone for 10 weeks. 81% of severe reactions occurred in the first year of treatment. 27% appeared to suffer from a severe reaction at the time of first contact. The ulnar nerve was most frequently affected. 33% of all reactors suffered from a silent neuritis. 75-80% of affected nerves improved either partially or totally. Treatment of severe reactions with prednisone appears to preserve or considerably improve the functions of the affected nerves. In many cases, the nerve's motor function was impaired with no loss in sensitivity. These findings confirm that well-instructed leprosy field workers are capable of detecting severe reactions on a timely basis and are competent to treat these complications adequately.