Information system for tuberculosis

Indonesia, with one of the world’s highest TB burdens, relies on SITB to track and manage tuberculosis cases nationwide. This study thoroughly evaluated SITB through a multimethod approach that included heuristic evaluation, user satisfaction surveys, and in-depth interviews with health workers.

The heuristic evaluation revealed multiple usability issues, most notably inconsistent terminology, inadequate error prevention, and interface design flaws that could hamper efficient reporting. Among these, limited data entry capability due to server constraints was a critical limitation affecting system performance during busy hours.

User satisfaction measured through the EUCS model showed generally positive perceptions, with an average satisfaction score of 4.08. However, dimensions like ease of use and timeliness fell below optimal levels. Users reported frustration over the slow response time and difficulties learning to use the system without formal training.

Qualitative interviews further illuminated operational challenges. Although recent integration with the civil registration system (Dukcapil) improved data completeness and reduced some manual work, users still had to enter duplicate information into separate systems, highlighting the need for seamless EMR integration.

The study emphasizes that while SITB has significantly modernized TB reporting in Indonesia, its full potential will only be realized through targeted enhancements—especially improving system performance, refining user support materials, and completing integration with EMR platforms.

These findings will serve as a roadmap for policymakers and system developers aiming to optimize SITB’s functionality and support Indonesia’s TB elimination goals by 2030.

Source:

1. Pratiwi, R.D., Alisjahbana, B., Subronto, Y.W., Priyanta, S. and Suharna, S., 2025. Implementation of an information system for tuberculosis in healthcare facilities in Indonesia: evaluation of its effectiveness and challenges. Archives of Public Health, 83(1), pp.1-18.

Syndemic of TB and diabetes

Tuberculosis and diabetes mellitus have emerged as a syndemic, with each condition exacerbating the other. Patients with both diseases experience diagnostic challenges, as diabetes can significantly delay TB diagnosis and treatment initiation. For example, studies in China demonstrate a fourfold longer median time from symptom onset to first healthcare contact among people with diabetes. Although some reports suggest quicker treatment initiation, the weight of evidence supports delayed diagnosis as a common scenario.

Clinical presentations in patients with concurrent TB and diabetes are frequently more severe. These include disseminated disease, cavitary lesions, and atypical radiographic features that can further complicate diagnosis and management. Poor glycemic control correlates with worse disease severity, underscoring the need for meticulous monitoring of glucose levels throughout TB treatment. Notably, many patients without prior diabetes can develop transient hyperglycemia during therapy, raising questions about optimal screening and retesting intervals.

Treatment outcomes are consistently poorer in patients with diabetes. These individuals have higher mortality rates, greater risks of relapse, longer times to sputum conversion, and increased likelihood of multidrug-resistant TB. The interplay between diabetes and TB medications, along with the higher pill burden, increases the risks of adverse effects and treatment interruptions. Furthermore, hyperglycemia, whether transient or chronic, predicts worse TB outcomes, pointing to a complex interaction beyond simple glucose elevation.

At the biological level, M. tuberculosis infection of adipose tissue may drive metabolic disruptions that mimic the inflammatory state seen in insulin resistance. This mechanistic link provides a plausible explanation for the bidirectional relationship between TB and dysglycemia. Diabetes impairs both innate and adaptive immunity against TB, compromising the host’s ability to clear infection and leading to higher bacterial loads.

Emerging evidence suggests that certain diabetes medications, such as metformin and statins, may exert beneficial effects on TB immunopathology, independent of their glucose-lowering properties. However, corticosteroids and some TB treatments may worsen hyperglycemia, necessitating careful therapeutic balancing. There is a clear need for rigorous studies, including randomized controlled trials and standardized registries, to clarify these interactions and optimize treatment strategies.

Overall, the syndemic of TB and diabetes requires integrated management approaches that address not only microbial eradication but also metabolic and immunological dysfunction. Enhanced screening, prompt diagnosis, tailored treatment regimens, and close glycemic monitoring will be crucial to improving outcomes in this vulnerable population.

Source:

1. Magodoro, I., Kotze, L., Stek, C.J., West, A., Le Roux, A., Sobratee, N., Taliep, A., Hamada, Y., Dave, J.A., Rangaka, M.X. and Parihar, S.P., 2025. Clinical, metabolic and immune interaction between tuberculosis and diabetes mellitus: implications and opportunities for therapies. Expert Opinion on Pharmacotherapy.

Tuberculosis in Peru

TB transmission [2]

A study investigates how TB spreads in urban Lima by analyzing over 2,500 culture-positive TB cases using whole-genome sequencing. Researchers assessed whether various demographic, social, and biological factors influence who transmits TB. They identified 1,447 direct transmission pairs based on genetic similarity and diagnosis timing.

Results showed that younger adults, males, smokers, and drinkers were more likely to be transmitters. Notably, incarceration history had a strong influence—if both individuals in a pair had been incarcerated, the likelihood of transmission increased over tenfold. Clinical features like cavitary disease and prior TB also raised the odds of transmission.

The study’s strength lies in using advanced genomic tools and a large cohort to clarify TB spread patterns in a community. These findings suggest that public health efforts should prioritize high-risk groups—especially former prisoners and substance users—to better curb TB transmission. Importantly, the study provides a template for using genomic data in real-world public health planning.

Smoking cessation in tuberculosis patients [1]

A study conducted in the metropolitan area of Lima, Peru, sought to investigate whether recent smoking cessation among pulmonary tuberculosis (TB) patients could reduce the risk of TB infection in their child household contacts compared to continued active smoking. Researchers enrolled newly diagnosed pulmonary TB patients and their household child contacts aged 15 years or younger between September 2009 and August 2012. At enrollment, patients' smoking histories were categorized as never smoked, distant quitters (ceased smoking more than two months prior to diagnosis), recent quitters (ceased smoking within two months of diagnosis), or active smokers. Tuberculosis infection among child contacts was assessed using the tuberculin skin test (TST) at baseline, six months, and twelve months.

The study population included 905 TB patients and 1811 child contacts, with 78% of the index patients classified as never smokers, 11.7% as distant quitters, 7.9% as recent quitters, and 2.5% as active smokers. At baseline, 24.4% of the child contacts tested TST-positive, a figure that rose to 37.3% by six months. Multivariate analysis showed that child contacts of recent quitters had a significantly lower risk of TB infection compared to those of active smokers, with adjusted risk ratios (aRR) of 0.45 at baseline and 0.48 at six months. Furthermore, the risk of infection among contacts of recent quitters was comparable to that among contacts of never smokers.

These findings suggest that children exposed to TB patients who had recently quit smoking had a significantly reduced risk of TB infection compared to those exposed to active smokers. Sensitivity analyses adjusting for disease severity, timing of quitting, and restricting to younger children confirmed the robustness of the results. Overall, the study highlights the potential for smoking cessation interventions to rapidly and effectively reduce TB transmission within households.

Source: 

1. Chu, A.L., Lecca, L.W., Calderón, R.I., Contreras, C.C., Yataco, R.M., Zhang, Z., Becerra, M.C., Murray, M.B. and Huang, C.C., 2021. Smoking cessation in tuberculosis patients and the risk of tuberculosis infection in child household contacts. Clinical Infectious Diseases, 73(8), pp.1500-1506.
2. Trevisi, L., Brooks, M.B., Becerra, M.C., Calderón, R.I., Contreras, C.C., Galea, J.T., Jimenez, J., Lecca, L., Yataco, R.M., Tovar, X. and Zhang, Z., 2024. Who transmits tuberculosis to whom: a cross-sectional analysis of a cohort study in Lima, Peru. American Journal of Respiratory and Critical Care Medicine, 210(2), pp.222-233.

Tuberculosis in the Philippines

BPaL Regimen Costs [2]

A research sought to fill a knowledge gap about the real-world economic burden of BPaL, a WHO-endorsed treatment for DR-TB, in the Philippines. By analyzing patient and provider costs using rigorous economic evaluation methods, the study found that BPaL substantially reduces direct and indirect costs for patients. The use of patient surveys and financial reviews allowed for detailed cost capture, adding strength to the cost-effectiveness conclusions.

Crucially, BPaL not only demonstrated lower costs but also superior treatment success rates compared to current regimens. These results are especially impactful given the high burden of DR-TB in resource-constrained settings like the Philippines. The study's robust design — including standardized patient selection and multiple data sources — supports its credibility.

From a policy perspective, the data suggest that transitioning DR-TB treatment toward the BPaL regimen could improve both patient outcomes and economic efficiency. Lower healthcare visits and reduced catastrophic expenditures further emphasize its advantage in practical, real-world implementation.

The economic analysis, including favorable ACER and ICER values under established GDP thresholds, clearly supports the adoption of BPaL. With cost and health advantages converging, the study makes a strong case for the national TB program to prioritize BPaL in routine care beyond the operational research context.

Outpatient DM Costs [1]

In 2021, diabetes mellitus (DM) outpatient visits accounted for 3% to 13% of total outpatient visits across 11 study sites in the Philippines. The study assessed various unit costs associated with DM services, including risk assessments at USD 0.53 and screenings using fasting blood sugar (FBS) at USD 2.99 when conducted with a chemistry analyzer. Random plasma glucose (RPG) screenings were slightly lower, costing USD 1.67, while the oral glucose tolerance test (OGTT), offered in only one private hospital, had the highest cost at USD 23.72. HbA1c testing was available in select facilities, further contributing to screening and diagnostic costs.

The weighted mean monthly drug cost per DM patient was estimated at USD 7.67, with metformin costing USD 2.11 per month and gliclazide ranging from USD 2.92 to USD 3.22, depending on dosage. Among injectable drugs, biphasic isophane human insulin was the most commonly prescribed, with an average monthly cost of USD 29.45. Staff time was the primary cost driver for outpatient services not requiring laboratory tests, accounting for 70% to 92% of costs, while consumables made up 52% to 90% of the expenses for screening and diagnosis services.

The cost per DM case detected among TB patients was lowest when using the RPG plus FBS algorithm at USD 17.43 per case, and HbA1c plus FBS at USD 25.41. When screening was limited to patients aged over 45 years, these costs decreased to USD 11.73 and USD 16.17 per case, respectively. Overall, the monthly cost per DM outpatient ranged from USD 8.95 for drug prescriptions alone to USD 12.36 when monitoring and consultations were included. These findings provide essential data to inform planning and budgeting for integrated TB-DM care, although further research is needed to explore inpatient costs and the patient perspective.

References:

1. Yamanaka, T., Castro, M.C., Ferrer, J.P., Solon, J.A., Cox, S.E., Laurence, Y.V. and Vassall, A., 2024. Health system costs of providing outpatient care for diabetes in people with TB in the Philippines. IJTLD open, 1(3), pp.124-129.
2. Evans, D., Hirasen, K., Casalme, D.J., Gler, M.T., Gupta, A. and Juneja, S., 2024. Cost and cost-effectiveness of BPaL regimen used in drug-resistant TB treatment in the Philippines. IJTLD open, 1(6), pp.242-249.

Quality of Life & Social Determinants

Immune Dysfunction in T2DM-TB Comorbidity

• T2DM significantly impairs immune response in individuals with latent TB, shown by reduced cytokine levels (e.g., IFNγ, IL-2, IL-17) and poor mycobacterial growth control.
• This immunological vulnerability underscores the biological basis for increased TB progression risk in diabetics.
• Feasible suggestion: Routine immune profiling in T2DM patients could help identify those at higher TB risk, guiding early preventive interventions.

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Demographic & Clinical Risk Factors

• Age, BMI, and low income are consistent risk factors for TB-DM comorbidity across studies; older adults and those with normal-to-high BMI are especially vulnerable.
• Educational level and number of TB symptoms are also associated with greater risk and poorer outcomes.
• Feasible suggestion: Target screening and education efforts at older, overweight individuals with low educational attainment to detect and manage comorbidity earlier.

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Programmatic Gaps & Health System Challenges

• DOTS implementation is widespread but suffers from irregular coordination, understaffing, inadequate training, and weak infrastructure (e.g., lack of diagnostic tools, IT resources).
• Reliance on donor funding creates long-term sustainability concerns.
• Feasible suggestion: Strengthen local health system capacity through stable government investment, staff training, and decentralization of diagnostic tools.

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Quality of Life & Social Determinants

• TB-DM patients report worse physical and mental well-being and face environmental barriers (e.g., housing, access to care).
• Despite clinical symptoms, social conditions and perceived quality of life are major burdens, particularly among the underprivileged.
• Feasible suggestion: Integrate social support (housing, transport, counseling) into TB-DM care models to improve treatment adherence and overall outcomes.

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Innovative Education & Early Prevention

• Educational storybooks effectively improved TB knowledge and behavior (like cough etiquette) in children of TB patients.
• The method was effective regardless of family health history or home environment, suggesting its standalone impact.
• Feasible suggestion: Expand storytelling-based interventions as low-cost, scalable tools in TB-endemic areas to promote early prevention and intergenerational awareness.

Yoseph Samodra

References:

1. Dasan, B., Rajamanickam, A., Pandiarajan, A.N., Shanmugam, S., Nott, S. and Babu, S., 2025. Immunological mechanisms of tuberculosis susceptibility in TB-infected individuals with type 2 diabetes mellitus: insights from mycobacterial growth inhibition assay and cytokine analysis. Microbiology Spectrum, 13(1), pp.e01445-24.
2. Araia, Z.Z., Mesfin, A.B., Mebrahtu, A.H., Tewelde, A.G., Osman, R. and Tuumzghi, H.A., 2021. Diabetes mellitus and its associated factors in tuberculosis patients in maekel region, eritrea: analytical cross-sectional study. Diabetes, Metabolic Syndrome and Obesity, pp.515-523.
3. Nuraisyah, F., Juliana, N., Astaria, D., Khalisah, N., Al Fatih, D.M.F., Dewi, S.K. and Marwati, T., 2024. Risk Factors of Pulmonary Tuberculosis in Type 2 Diabetes Mellitus in Yogyakarta. Journal of Epidemiology and Public Health, 9(2), pp.194-203.
4. Sofiana, L., Muthiah, T.A.S. and Putri, N. (2024) Analysis of directly observed treatment shortcourse implementation as an effort to control tuberculosis in Yogyakarta. The Indonesian Journal of Public Health, 19(3), pp. 507–519.
5. Nugrahaeni, D.K., Kusumasari, I., Budiana, T.A., and Mauliku, N.E. (2025). Factors Associated with Tuberculosis-Diabetes Mellitus Comorbidity. Periodic Epidemiology Journal/Jurnal Berkala Epidemiologi, 13(1):75-84.
6. Penyami, Y., Angkasa, M.P. and Sumarni, S., 2025. Using storybooks to enhance health awareness among schoolchildren at risk of tuberculosis. Malahayati International Journal of Nursing and Health Science, 7(11), pp.1338-1343.

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Tackling The Spread

1. Structural & Environmental Drivers of TB Spread

• Overcrowding and poor prison conditions (e.g., Lhokseumawe Prison at 400% capacity) significantly increase TB transmission risk.
• Housing conditions, like inadequate ventilation and high density, though intuitively risky, showed no direct statistical link in one study—but malnutrition was strongly associated with TB incidence (OR ≈ 4.6).
• Climate variables (minimum temperature, rainfall) in Brunei showed delayed but significant links to TB incidence, suggesting environmental factors may indirectly drive TB via behavior or immunity shifts.
• Feasible interventions: Decongest prisons and improve inmate health screenings. Address nutrition systematically in vulnerable communities and facilities. Incorporate climate-related surveillance in TB forecasting in tropical areas.

See also: Lin TB Lab NTU

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2. Biological and Comorbidity Risk Factors

• Comorbidities, especially diabetes, are major risk amplifiers for TB (Odds Ratios > 5).
• In Brunei, 33.9% of TB patients had diabetes, with older age, renal disease, and hypertension also significantly linked.
• SGLT2 inhibitors (e.g., dapagliflozin, empagliflozin) in diabetic TB patients showed substantial mortality reductions—up to 92% lower one-year mortality in high-dose users.
• Feasible interventions: Integrate diabetes screening and management in TB control programs. Investigate and consider off-label use or trials of SGLT2-i for comorbid TB-DM patients in high-burden areas.

See also: BMRC Indonesia

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3. Social Determinants & Stigma

• Stigma (internal and external) leads to delayed care, treatment dropouts, and isolation.
• Internal shame and societal rejection were consistent across Southeast Asian studies.
• TB is reinforced as a "disease of poverty", with low-income communities bearing the heaviest burdens.
• Feasible interventions: Design community-based anti-stigma campaigns and peer support systems. Tackle structural poverty and improve healthcare access as part of TB elimination strategies.

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4. Innovation Gaps in Diagnostics, Vaccines, and Surveillance

• Diagnostic and vaccine tools are decades outdated (e.g., BCG, Mantoux).
• WHO’s End TB goals are faltering—only 1.5% annual incidence reduction vs. 10% target.
• Promising tools: Xpert Ultra, QuantiFERON for better diagnostics. Genomic sequencing and PET/CT imaging show promise but are costly.
• Feasible interventions: Scale up use of WHO-recommended molecular diagnostics. Build national capacity for TB surveillance and genomics, especially in LMICs.

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5. Research, Policy, and System Reform

• Top-down global TB strategies need restructuring.
• Emphasis on local leadership, reduced red tape, and context-sensitive research models.
• Cohort studies (Brunei, Taiwan, Aceh) show the value of real-world, data-driven insights into localized TB risks.
• Feasible interventions: Support local TB program autonomy with funding and technical support. Encourage collaborative research hubs in high-burden regions. Align national policies with WHO’s integrated TBDM framework and climate-health surveillance insights.

Yoseph Leonardo Samodra

References:

1. Khairunnisa C, Mardiati, Millizia A, Wahyuni S, Nabilah Lubis P, Ikhsan M. Risk Factors for Pulmonary Tuberculosis Transmission Among Prisoner in Correctional Facilities in Lhokseumawe City, Aceh, Indonesia. Natl J Community Med 2025;16(6):582-588.
2. Pradana, T.L.C., Putra, B.T.W. and Utami, W.S., 2025. Stigma Tuberkulosis Paru di Asia Tenggara: Systematic Literatur Review. MAHESA: Malahayati Health Student Journal, 5(6), pp.2501-2512.
3. Syahrani, F., Lestari, H. and Irma, I., 2025. Faktor Risiko Kejadian TBC pada Usia Produktif di Puskesmas Poasia, Kota Kendari Tahun 2024. Jurnal Kendari Kesehatan Masyarakat, 4(3), pp.221-229.
4. Wright K. Tackling Tuberculosis: The Current Landscape and Future Directions. EMJ Microbiol Infect Dis. 2025;6[1]:26-30.
5. Lee, C.S., Ho, C.H., Liao, K.M., Wu, Y.C. and Shu, C.C., 2025. The impacts of SGLT2 inhibitors on the mortality of patients with tuberculosis. Journal of Infection and Public Health, p.102686.
6. Omar, N., Wong, J., Thu, K., Alikhan, M.F. and Chaw, L., 2021. Prevalence and associated factors of diabetes mellitus among tuberculosis patients in Brunei Darussalam: a 6-year retrospective cohort study. International Journal of Infectious Diseases, 105, pp.267-273.
7. Chaw, L., Liew, S.Q. and Wong, J., 2022. Association between climate variables and pulmonary tuberculosis incidence in Brunei Darussalam. Scientific Reports, 12(1), p.8775.

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