Indoor environmental conditions were associated with pediatric pulmonary TB

Who

Children aged 0–14 years living in Sambas District, West Kalimantan. The study included 62 cases of pediatric pulmonary TB and 62 controls without TB.

What

The study examined how indoor environmental conditions—air circulation, natural lighting, housing density, cigarette smoke exposure, bedroom orientation, family history of pulmonary TB, and maternal knowledge—were associated with pediatric pulmonary TB.
Key findings: Significant associations were found for:

• Housing density (RR = 3.847)

• Ventilation adequacy (RR = 2.208)

• Natural lighting (RR = 3.024)

• Bedroom orientation (non-east-facing) (RR = 2.879)

• Family history of pulmonary TB (RR = 9.818)

Cigarette smoke exposure (RR = 1.245) and maternal knowledge showed no significant association.

When

Data were collected from July to October 2023.

Where

The study took place in Sambas District, located in West Kalimantan Province, Indonesia.

Why

The research aimed to evaluate whether indoor environmental conditions and household characteristics contribute to the occurrence of pulmonary TB in children, addressing a local public health concern regarding TB transmission risk factors.

How

An analytical observational study with a case-control design was conducted. Primary data were collected using observation sheets and direct measurements of air circulation, natural lighting, and housing density. Statistical analysis assessed the relationship between household environmental factors and pediatric TB incidence.

Source: Syukur, A., Yulia, Y. and Istikomah, N.R., 2024. Hubungan Kondisi Lingkungan Rumah Dengan Kejadian Tb. Paru Pada Anak Di Kabupaten Sambas. Journal of Innovation Research and Knowledge, 4(6), pp.3795-3806.

Prevalence and treatment outcomes of LTBI among older patients with COPD in Taiwan

Who

• Population: Older adults (>60 years) with COPD diagnosed per GOLD 2023 criteria (FEV₁/FVC <70%).

• Sample: 920 eligible; 819 (89.0%) underwent LTBI screening.

  • IGRA-positive: 193 (23.6%); IGRA-indeterminate: 9 (1.1%).

  • TPT recipients: 150 IGRA-positive participants (77.7% of positives).

• Demographics: Mean age ~72 years; majority male (~85%).

• Key comorbidities: Hypertension (53.8%), hyperlipidemia (33.7%), asthma (33.1%).

• Risk behaviors: 24.3% current smokers; high cumulative smoking exposure among IGRA-positive individuals.

What

• Focus: Determining the prevalence and predictors of latent tuberculosis infection (LTBI) among older COPD patients and evaluating completion and safety of various LTBI treatment regimens.

• Main findings:

  • LTBI prevalence: 23.6% via IGRA.

  • Predictors of IGRA positivity: Greater smoking pack-years, longer COPD duration, current smoking, history of cerebrovascular accident, inhaled corticosteroid (ICS) use, and cumulative prednisolone dose >210 mg in 2 years.

  • Treatment completion: Overall TPT completion 82.0%; highest in 3HP (91.2%), lowest in 9H (50.0%).

  • Safety: Adverse drug reactions (ADRs)—especially systemic drug reactions (SDRs) and hepatotoxicity—were the leading cause of discontinuation. Ten patients experienced AECOPD during treatment; four deaths occurred (three respiratory, one cardiac and unrelated to LTBI therapy).

• Implications: Older COPD patients have substantial LTBI prevalence and multiple clinical predictors; shorter rifapentine- or rifampin-based regimens showed higher completion rates but notable SDR risk.

When

• Study period: January 2021 – February 2024.

Where

• Setting: Prospective multicenter study in Taiwan at:

  • Taichung Veterans General Hospital

  • Kaohsiung Medical University Hospital

  • National Taiwan University Hospital and affiliated centers.

Why

• Rationale: COPD patients are at high risk for reactivation TB, yet LTBI prevalence, predictors, and regimen-specific outcomes in this population are insufficiently defined. Understanding these factors is essential for optimizing LTBI strategies and supporting TB elimination efforts.

How

• Design: Prospective multicenter cohort.

• Screening: IGRA using QuantiFERON-Gold or Gold-Plus.

• Treatment: WHO-recommended LTBI regimens (1HP, 3HP, 3HR, 4R, 9H) chosen via shared decision-making and administered under directly observed preventive therapy (DOPT/eDOPT).

• Monitoring:

  • Baseline labs (CBC, liver/renal panel, hepatitis, HIV).

  • Daily or dose-based ADR monitoring; monthly or biweekly biochemical testing depending on regimen.

  • ADR causality assessed using Naranjo score; severity guided management.

• Analysis: Baseline comparisons and multivariate logistic regression to identify predictors of IGRA positivity; regimen-wise assessment of completion and ADRs.

Source: Huang, H.L., Cheng, M.H., Lee, M.R., Chien, J.Y., Lu, P.L., Sheu, C.C., Wang, J.Y., Chong, I.W., Yang, J.M. and Huang, W.C., 2025. Prevalence and treatment outcomes of latent tuberculosis infection among older patients with chronic obstructive pulmonary disease in an area with intermediate tuberculosis burden. Emerging Microbes & Infections, 14(1), p.2497302.

Recurrence of TB and associated risk factors among Non-HIV patients in Taiwan

Who

• Study population: 1,875 patients with active tuberculosis (TB) who completed anti-TB treatment at a referral medical center in Taiwan.

• Subgroups:

  • 1,514 (80.7%) with pulmonary TB.

  • 1,342 culture-confirmed pulmonary TB cases.

  • 361 (19.3%) with extrapulmonary TB.

• Demographics: Median age 67 years; 67% male; comorbidities included diabetes (21.2%), malignancy (14.4%), prior TB (11.1%); 34.3% smokers; 9% had cavitary disease; 35.5% sputum smear–positive.

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What

• Focus: Determine TB recurrence rate within 6 years after treatment and identify risk factors for recurrence; evaluate annual recurrence patterns from 2012–2019.

• Major findings:

  • Overall TB recurrence rate: 2.0% (434 per 100,000 person-years).

  • Recurrence highest in the second year post-treatment.

  • Recurrence declined in patients diagnosed after 2017.

  • Independent risk factors for recurrence:

    • BMI < 20 kg/m² (aHR ~4.4–5.0)

    • Prior TB history (aHR ~4.3–4.4)

    • 2-month sputum culture non-conversion (aHR ~3.4–4.4)

  • Recurrence risk increased with cumulative risk factors (10.8% with two; 28.6% with all three).

• Implications: Early culture conversion and nutritional status are key for risk stratification; past TB history strongly predicts recurrence; supports tailored follow-up intensity and resource allocation.

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When

• Diagnosis and inclusion period: January 1, 2012 – December 31, 2019.

• Follow-up duration: Up to 6 years post-treatment, with follow-up ending December 31, 2022.

• Median follow-up: 72 months.

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Where

• Conducted at a single referral medical center in Taiwan, a region with moderate TB burden.

• Data linked with the Taiwan CDC notification database.

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Why

• To identify clinical predictors of TB recurrence to enable risk-stratified and individualized TB management, determine who may need prolonged therapy or closer monitoring, and optimize public health resource deployment.

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How

• Study design: Single-center retrospective cohort.

• Eligibility: Bacteriologically confirmed or clinically diagnosed active TB; completed ≥6 months of guideline-based treatment; excluded those who died or were lost before treatment completion, or had HIV.

• Data collected: Demographics, comorbidities, radiologic findings, microbiology including drug resistance, treatment adherence, and sputum culture conversion at 1 and 2 months.

• Outcome definitions: TB recurrence per WHO criteria (relapse or reinfection).

• Statistical approach:

• Cox proportional hazards regression for risk factor identification.

• Kaplan–Meier survival curves.

• Death treated as a censoring event; recurrence rates expressed per person-years.

• Subgroup analyses for pulmonary and culture-confirmed pulmonary TB.

Source: Hsu, C.M., Wu, C.J., Chang, C.J., Pan, S.W., Tseng, Y.H., Huang, J.R., Su, W.J., Feng, J.Y. and Chen, Y.M., 2025. Recurrence of tuberculosis and associated risk factors among Non-HIV patients in Taiwan: A retrospective cohort study. Journal of Infection and Public Health, p.102912.

Determinants of Treatment Interruption Among Drug-Resistant Tuberculosis Patients in Medan

Who

• Participants: 104 bacteriologically confirmed DR-TB patients at H. Adam Malik General Hospital, Medan.

• Groups: 34 patients lost to follow-up and 70 who continued treatment.

• Demographics of loss-to-follow-up patients:

  • 65% aged 45–65

  • 55.9% male

  • 91.2% completed high school or equivalent

  • 58.8% employed

  • 70.6% married

What

• Study focus: Association between perceived social support and perceived quality of healthcare services with loss-to-follow-up among DR-TB patients.

• Key findings:

  • Low–moderate social support significantly predicts loss-to-follow-up (PR = 14.50; p < 0.001).

  • Patients perceiving only “adequate” healthcare provider support have nearly a six-fold higher risk of loss-to-follow-up compared with those perceiving full support (p < 0.001).

• Implications: Both social and healthcare support strongly influence treatment adherence and should be integrated into patient-centered TB management strategies in Indonesia.

When

• The study was conducted over seven months; patients included had initiated treatment between 2020 and 2024.

Where

• H. Adam Malik Hospital, Medan, Indonesia. 

Why

• To fill a gap in understanding how combined social support and healthcare service quality predict loss-to-follow-up among DR-TB patients—an area with limited evidence in Medan.

How

• Design: Observational study using purposive sampling.

• Inclusion criteria: Age ≥18 years, DR-TB default or treatment completion status, treatment initiation 2020–2024, and informed consent.

• Data collection: Medical record review plus a validated questionnaire covering demographics, treatment attitude, social support, and healthcare provider support.

• Instruments: Social support assessed using adapted versions of the MSPSS (Multidimensional Scale of Perceived Social Support) questionnaire (12 items, 3 subscales).

Source: Dalimunthe, A., Sinaga, B.Y.M., Siagian, P. and Amelia, R., 2025. Social Support and Healthcare Service Quality as Determinants of Treatment Interruption Among Drug-Resistant Tuberculosis Patients in Medan, Indonesia. Jurnal Impresi Indonesia, 4(11), pp.5176-5183.

Respiratory isolation for tuberculosis

Tuberculosis has been recognized for thousands of years, and its story reflects the evolution of medicine itself. In the early Hippocratic corpus of the 5th–4th century BCE, chronic wasting lung diseases—likely including tuberculosis—were grouped under phthisis, meaning “to waste away.” The Hippocratic school believed the illness to be hereditary, a view shaped by its appearance among cohabitating family members. The idea of contagion surfaced in Classical Greece: Isocrates acknowledged possible transmission, while Aristotle noted that scrofulous disease in livestock could spread through “foul air.” Galen, writing in the second century BCE, leaned toward a contagious explanation and recommended treatments such as fresh air, milk, and sea voyages. Yet physicians in the Galenic tradition largely favored the miasma theory—the belief that disease arose from inhaling noxious vapors—so individuals with phthisis were not stigmatized during Greek and Roman times.

By the Middle Ages, scrofula had gained a new cultural identity. Known as the “king’s evil,” it was believed curable by the royal touch of English and French monarchs, and sufferers were sometimes treated like lepers. A shift in thinking emerged toward the end of the 18th century, when physicians encouraged patients with advanced disease to remain at home, emphasizing diet, gentle physical exercise, and fresh air rather than long, arduous journeys to coastal spas or dry climates.

The sanatorium era began in 1859, when Herman Brehmer opened the first tuberculosis sanatorium in Gobersdorf, in the Silesian Mountains. These institutions originated as therapeutic rather than public health responses. Mountain air was thought to have curative power, and Brehmer believed that TB patients had abnormally small hearts; he theorized that high-altitude air would strengthen the heart and improve health. The model spread internationally. In the United States, Edward Livingston Trudeau—himself diagnosed with tuberculosis in the early 1870s—opened the nation’s first sanatorium at Saranac Lake in 1884. The first patients were housed in the modest “Little Red” cottage, and Trudeau credited the restorative Adirondack climate with extending his life until 1915.

Even as sanatoria expanded, the scientific understanding of tuberculosis advanced dramatically. In the Islamic Golden Age, Avicenna (980–1037 CE) described phthisis as contagious and recommended isolating patients. During the Renaissance, Girolamo Fracastoro (1478–1553 CE) proposed an early germ-like theory, suggesting that diseases spread through tiny “seed-like” particles. But it was not until the 19th century that definitive evidence emerged. Inspired by Pasteur’s work, Jean Antoine Villemin demonstrated in the 1860s that tuberculosis was infectious, though he could not yet identify the organism responsible. The breakthrough came on 24 March 1882, when Robert Koch announced his discovery of the tubercle bacillus—Mycobacterium tuberculosis—and established its role through what would become known as Koch’s postulates. His work also confirmed that the disease spread directly between people via airborne droplets.

Diagnostic techniques improved quickly. Paul Ehrlich refined Koch’s staining methods, and later modifications by Ziehl and Neelsen produced the famous acid-fast stain still used in much of the world today to identify tuberculosis in sputum samples.

The mid-20th century brought the true revolution: effective antibiotic therapy. In 1941, Jörgen Lehmann, working with the Swedish firm Ferrosan, showed that para-aminosalicylate (PAS) inhibited tubercle bacteria and protected infected animals. That same year, Selman Waksman and Albert Schatz at Rutgers University isolated streptomycin from Streptomyces griseus, demonstrating its lifesaving potential in both animal models and humans. Sanatoria continued to operate into the 1960s—mainly to prevent relapse—but their importance waned rapidly with the arrival of powerful drug combinations. The discovery of isoniazid in 1952 allowed near-universal cures when given alongside streptomycin and PAS. Additional breakthroughs soon followed: rifampicin in the mid-1960s, and recognition of pyrazinamide’s sterilizing activity in the early 1970s, enabling the fully oral six-month regimen that remains the standard for treating drug-susceptible TB today.

To bridge the gap between clinical efficacy and real-world adherence, public health programs adopted directly observed therapy (DOT), in which patients take medications under supervision to ensure consistent, effective treatment. This approach, used worldwide, helps prevent relapse and reduces ongoing transmission in the community.

Source: Karakousis, P.C. and Mooney, G., 2025. Respiratory isolation for tuberculosis: a historical perspective. The Journal of Infectious Diseases, 231(1), pp.3-9.

Variation of TB prevalence across diagnostic approaches and geographical areas of Indonesia (2021) N005

A study utilized data obtained from the Health Research and Development Agency of the Tuberculosis Unit, Indonesian Ministry of Health (HRDA-MoH). The dataset included diagnostic information gathered through sputum acid-fast bacilli (AFB) examination, sputum culture, sputum genetic testing, and chest X-ray assessments. 

The original dataset covered all 34 provinces of Indonesia, which were grouped into three major regions: Sumatra, Java-Bali, and other islands (primarily in the eastern part of the country with smaller populations). A stratified multi-stage cluster sampling method was applied during the primary data collection to ensure representative coverage. The inclusion criteria comprised individuals aged 15 years and older who had resided in the selected clusters for at least one month. Individuals living in institutional or temporary settings such as military barracks, dormitories, hospitals, diplomatic residences, and hotels were excluded.

In the field, all chest X-ray images collected were sent to a central reading team for evaluation by three independent radiologists who were blinded to the field screening results. The images were classified as normal, abnormal with TB or non-TB features, or other findings. TB-related abnormalities included infiltrates, nodules, consolidation, cavitary lesions, fibrosis, calcification, pleural effusion, and pleural thickening. The central readings were used to establish the case definition for TB, while field readings guided sputum sample collection. Out of 15,446 participants, 11,202 had abnormal X-ray results, and notably, 43.6% of participants with positive X-ray findings reported no symptoms such as persistent cough or hemoptysis.

Findings from the chest X-ray readings showed a TB prevalence of 725.2 per 100,000 population aged 15 years and older. The highest prevalence occurred among individuals aged 15–24 years, with 783.8 per 100,000 population. Males had a higher prevalence (200.8 per 100,000) compared to females (133.5 per 100,000). Regional analysis revealed that the “other regions” category had the highest prevalence (864 per 100,000), followed by Sumatra and Java-Bali. The rates were generally higher in rural areas. These results underscored the substantial burden of undiagnosed or asymptomatic TB cases detected through radiographic screening.

For the sputum AFB examination, TB diagnosis was determined by identifying acid-fast bacilli in unprocessed sputum samples using the Ziehl–Neelsen staining technique. The TB prevalence based on AFB results was 256.5 per 100,000 population. The rate increased with age, peaking among those aged 65 years and older (527.6 per 100,000), and was lowest among the 15–24-year age group (137.5 per 100,000). The prevalence was markedly higher in males (392.5 per 100,000) than in females (131.0 per 100,000). Urban areas and the Sumatra region showed the highest AFB-based TB prevalence, suggesting potential demographic and regional disparities in TB infection or detection.

The culture-based diagnostic results were derived from both spot and morning sputum samples using the Lowenstein–Jensen medium. Some contamination was noted, particularly in spot sputum samples. The prevalence of culture-positive TB was 545.0 per 100,000 population, while culture-negative TB prevalence reached 945.5 per 100,000. Consistent with other diagnostic results, prevalence was higher among males (607.9 per 100,000) than females (463.0 per 100,000) and higher in urban areas than rural ones. The “other islands” region showed the highest culture-positive TB rate at 2,129.8 per 100,000 population. TB prevalence increased with age, with the highest rate found among participants aged 65 years and older (678.9 per 100,000).

Sputum genetic testing was performed using the Xpert MTB/RIF assay, an automated nucleic acid amplification technique that detects Mycobacterium tuberculosis and rifampicin resistance. The analysis identified 213 MTB-positive samples, consisting of 184 rifampicin-susceptible, 19 rifampicin-resistant, and 10 indeterminate cases. The estimated TB prevalence based on this method was 894.9 per 100,000 population. Regional distribution showed the highest prevalence in the “other regions” (941.2 per 100,000), followed by Sumatra (875.0 per 100,000) and Java-Bali (838.7 per 100,000). The highest prevalence by age group was found among individuals aged 35–44 years (933.3 per 100,000). Slight differences were noted between males and females, with slightly higher rates in males and in urban populations.

Overall, this secondary data analysis concluded that the national TB prevalence among individuals aged 15 years and older was 759.1 per 100,000 population (95% CI: 589.7–960.8). TB prevalence increased steadily with age, reaching its highest level among individuals aged 65 years and older (1,581.7 per 100,000). Urban areas consistently demonstrated higher TB prevalence across all diagnostic methods compared to rural areas, and the Sumatra region recorded the highest regional rates. These findings highlight the persistent burden of tuberculosis in Indonesia and the need for comprehensive diagnostic strategies that combine clinical, radiological, and molecular methods to improve detection and control efforts nationwide.

Source: Noviyani, A., Nopsopon, T. and Pongpirul, K., 2021. Variation of tuberculosis prevalence across diagnostic approaches and geographical areas of Indonesia. PLoS One, 16(10), p.e0258809.

Diagnostic methods for tuberculosis and their applicability in Indonesia (2019) N004

Overview of Tuberculosis (TB) Diagnostic Methods

• Tuberculin Skin Test (TST):

  • The TST is a delayed-type hypersensitivity reaction used to detect TB infection.

  • Limitations: Includes cross-reactivity with other antigens, low sensitivity and specificity, and false-positive results—especially in individuals vaccinated with BCG.

  • Procedure: Involves intradermal injection of purified protein derivative (PPD).

  • Interpretation:

    • ≥5 mm induration: positive in immunocompromised patients.

    • ≥10 mm: positive in immunocompetent children and unvaccinated adults.

    • ≥15 mm: positive in vaccinated individuals.

  • Accuracy:

    • Sensitivity/Specificity:

      • Immunocompromised: 100% / 90.3%

      • Immunocompetent: 97.2% / 91.9%

      • Vaccinated: 86.1% / 94.2%

  • Cross-reactivity with BCG and environmental mycobacteria may yield up to 86.1% false positives in vaccinated persons.

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• Interferon-Gamma Release Assay (IGRA):

  • Measures the interferon-gamma (IFN-γ) response to TB-specific antigens such as ESAT-6, CFP-10, and TB7.7.

  • Uses ELISA (e.g., QuantiFERON®-TB Gold In-Tube) or ELISpot (e.g., T-SPOT®.TB™) techniques.

  • Advantages:

    • Higher specificity than TST.

    • Not affected by BCG vaccination.

    • Especially useful for diagnosing TB in immunocompromised and TB-HIV co-infected patients.

  • Clinical Utility: Preferred for screening latent TB in patients with inflammatory diseases or compromised immunity.

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• GeneXpert MTB/RIF Assay:

  • A cartridge-based nucleic acid amplification test (NAAT) using quantitative real-time PCR (qRT-PCR).

  • Detects M. tuberculosis DNA and rifampicin resistance within 2 hours.

  • Key Features:

    • Closed amplification system minimizes cross-contamination.

    • Detects mutations in the rpoB gene, responsible for ~96% of rifampicin resistance.

    • Identifies bacteria in both positive and negative smears.

    • Can process multiple specimen types (sputum, CSF, pleural fluid, etc.).

  • Limitations:

    • False positives: due to target amplification errors.

    • False negatives: due to poor sample quality, PCR inhibitors, or reagent issues.

    • Requires stable electricity, temperature below 30°C, and regular equipment calibration.

    • Uses Bacillus globigii spores as internal controls for quality assurance.

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Transmission Factors of Tuberculosis

• Infectivity and Disease Severity:

  • Determined by sputum smear results and chest X-rays.

• Contact History and Duration:

  • Prolonged and frequent exposure increases infection risk.

• Environmental Conditions:

  • Transmission is higher in enclosed, poorly ventilated spaces.

• Strain Virulence:

  • Some M. tuberculosis strains are more infectious; extrapulmonary strains tend to cause greater macrophage damage than pulmonary strains.

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Diagnostic Indicators and Methods

• Clinical and Radiological Findings:

  • Positive acid-fast bacillus (AFB) smear or abnormal chest X-ray supports TB infection.

  • Radiographic signs include hilar lymphadenopathy, consolidation, pleural effusion, miliary lesions, atelectasis, calcifications, and tuberculoma.

• Diagnostic Workflow:

  1. AFB staining (Ziehl-Neelsen, Kinyoun–Gabbet, or Auramine-Rhodamine).

     • Fast and inexpensive; sensitivity ≈70%.

     • Operator-dependent; negative results may require further culture testing.

  2. Culture method – the gold standard.

     • Specimens: sputum, urine, CSF, pleural fluid, pus, or tissue biopsy.

     • Detects smear-negative cases and allows drug susceptibility testing.

     • Solid media: Lowenstein–Jensen, Ogawa, Middlebrook 7H10/7H11.

     • Liquid media: MGIT™ 960, Bactec™ 9000MB.

     • Higher sensitivity (10–10² CFU/ml) but slow growth (up to 8 weeks).

     • Requires skilled personnel and proper biosafety infrastructure.

  3. Serological assay (TST/Mantoux) – identifies delayed-type hypersensitivity.

  4. IGRA – measures IFN-γ response to TB-specific antigens.

  5. NAAT (GeneXpert MTB/RIF) – rapid molecular detection of TB and resistance markers.

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Diagnostic Test Performance and Availability (Summary Table)

Test	Sensitivity (%)	Specificity (%)	Availability in Indonesia
NAAT-TB detection	85	97	Limited to some labs
NAAT (GeneXpert MTB/RIF)	>92	>99	Limited to tertiary hospitals
AFB microscopy	70	≥90	Widely available
Growth detection – Liquid	90	99	Referral hospitals / some labs
Growth detection – Solid	88	99	Referral hospitals / some labs
DNA probe/HPLC identification	99	100	Research labs only
First-line drug susceptibility (liquid)	≥97	≥97	Referral hospitals / some labs
Second-line drug susceptibility (liquid)	≥92	≥97	Referral hospitals / some labs
Second-line drug susceptibility (solid)	82–99	92–100	Referral hospitals / some labs

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Tuberculosis (TB) Diagnosis in Indonesia

• General Diagnostic Approach:

  • In Indonesia, TB diagnosis is established based on a combination of clinical assessment, laboratory findings, and supporting examinations.

  • The main laboratory tests include:

    • Direct microscopic examination of sputum smears for Acid-Fast Bacilli (AFB).

    • Culture tests, using either:

      • Solid media (Lowenstein–Jensen / LJ), or

      • Liquid media (Mycobacteria Growth Indicator Tube / MGIT™ system).

    • Rapid molecular tests, particularly the GeneXpert MTB/RIF assay, which detects M. tuberculosis and rifampicin resistance.

      • Note: This test is used for diagnosis, not for treatment monitoring.

  • Supporting examinations may include radiological imaging (chest X-ray) and histopathological analysis when extrapulmonary TB is suspected.

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National Diagnostic Workflow (Ministry of Health, Indonesia)

• The Indonesian Ministry of Health provides a standardized diagnostic algorithm for TB, emphasizing stepwise evaluation and case confirmation:

  • Step 1 – Clinical Evaluation:

    • Adult patients presenting with a productive cough lasting ≥2 weeks undergo a detailed clinical examination.

  • Step 2 – Sputum Microscopy:

    • Patients are instructed to submit three sputum samples for microscopic AFB examination.

    • If any one sample is positive, the diagnosis of TB is confirmed, and treatment is initiated.

  • Step 3 – Further Testing (if microscopy negative):

    • If microscopy results are negative but clinical suspicion remains high, the patient should be referred for:

      • Chest X-ray, and/or

      • Additional tests, such as a rapid molecular assay (GeneXpert MTB/RIF) or culture.

    • A suggestive chest X-ray may justify starting TB treatment even when smear results are negative.

  • Step 4 – Limited Access Situations:

    • In healthcare settings where referral or advanced diagnostics are not possible:

      • The patient may receive a trial of broad-spectrum antibiotics.

      • Re-evaluation is conducted after treatment:

        • If symptoms improve, TB is unlikely (non-TB diagnosis).

        • If symptoms persist, repeat clinical and sputum microscopic assessments are warranted.

  • Step 5 – Drug Susceptibility Testing (DST):

    • If M. tuberculosis is successfully cultured, DST should be performed to guide effective treatment and detect potential drug resistance.

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Challenges and National Response

• Despite the presence of structured diagnostic systems, many TB cases remain unreported in Indonesia.

• To address this, several strategic measures have been implemented:

  • Mandatory TB case notification for all health facilities, including public and private hospitals, to ensure comprehensive case reporting.

  • Strengthened collaboration between healthcare sectors to identify and record patients under TB treatment.

  • Integration of GeneXpert testing into the national TB prevalence survey, enhancing case detection accuracy.

    • Previously, the survey relied on:

      • Screening for cough ≥2 weeks, and

      • Diagnosis based solely on microscopy.

    • Since 2013–2014, improved methods have been adopted:

      • Screening includes both symptom assessment and X-ray findings.

      • Diagnosis incorporates smear microscopy, culture, and GeneXpert confirmation for smear-positive samples.

• As a result of active case finding and mandatory notification, TB detection rates have significantly improved nationwide since 2016.

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Source: Susilawati, T.N. and Larasati, R., 2019. A recent update of the diagnostic methods for tuberculosis and their applicability in Indonesia: a narrative review. Medical Journal of Indonesia, 28(3), pp.284-91.

Impact of the TB response in Taiwan N003

Taiwan’s demographic and public health infrastructure has been central to shaping its TB control efforts. The island has experienced rapid demographic transitions, with fertility rates dropping from 7 births per woman in 1951 to 1.09 in 2023, one of the lowest globally. By 2023, only 135,571 newborns were registered, marking the lowest in history, while 18% of the population was aged 65 years or older—a figure projected to reach 20% by 2025, classifying Taiwan as a super-aged society. Despite these demographic pressures, Taiwan has achieved substantial progress in TB control, reducing incidence from 73 per 100,000 in 2005 to 28 in 2023, with mortality dropping from 4.3 to 1.9 per 100,000 over the same period.

These achievements reflect long-standing investments and political commitment. The Taiwan CDC, established in 1999, integrated TB control under a centralized framework, with funding fully covered by the central government. The National TB Program (NTP) introduced milestone initiatives, including the “Ten-Year Halving Tuberculosis Plan” (2006–2015), followed by the “End TB by 2035 Project” (Phase I: 2016–2020; Phase II: 2021–2025), with preparations for Phase III underway. Mandatory case reporting under the Communicable Disease Control Act is strictly enforced, with penalties for physicians and institutions failing to report, while surveillance systems such as the Notifiable Infectious Disease Reporting System (NIDRS), Laboratory Automated Reporting System (LARS), and the National TB Management System ensure comprehensive monitoring and timely data integration.

Taiwan’s National Health Insurance (NHI) plays a crucial role by ensuring universal coverage for 99% of residents. Since 1997, the “No Reporting, No Reimbursement” policy has tied reimbursement of TB services to mandatory notification, incentivizing complete case reporting. Patients can access TB diagnosis and treatment through all hospitals and nearly 90% of private clinics contracted with NHI. To encourage timely diagnosis and treatment, copayments for TB and latent TB infection (LTBI) patients are fully reimbursed by Taiwan CDC, and care for uninsured individuals is also covered. This financial safety net has minimized both patient delays and health system delays in seeking TB care.

A comprehensive patient support structure strengthens these systems. Around 700 TB case managers under a Pay-for-Performance (P4P) scheme coordinate care between clinics and public health services, while 2,500 public health nurses at 374 centers provide education, monitor adherence, and conduct contact tracing. Since 2006, Taiwan has adopted a people-centered Directly Observed Therapy (DOT) program, with government-employed DOT workers assigned to each patient. This model has significantly reduced treatment interruption, loss to follow-up, and TB-specific mortality, maintaining recurrence rates below 1% since 2008. In 2015, Taiwan introduced electronic DOT (eDOT) to enhance accessibility and privacy, which gained renewed traction after the launch of eDOT 2.0 in late 2023.

Special attention has also been given to foreign-born populations, particularly migrant workers, who exceeded 700,000 in 2023 and now account for over 9% of TB cases. Health examinations are mandated shortly after arrival and at regular intervals. Previously, workers diagnosed with TB were repatriated, but regulatory changes since 2014 have allowed them to stay for treatment under DOT. Further amendments in 2015 and 2022 shifted the decision-making power to workers themselves, dramatically increasing the proportion remaining for treatment from 10.6% in 2014 to nearly 89% in 2022. These reforms have improved TB notification among foreign patients, raising timely reporting rates to over 96%.

To alleviate the economic burden of TB, Taiwan provides targeted financial support. The Taiwan Anti-Tuberculosis Association offers an annual grant of USD 31,000 to support low-income patients lacking social welfare resources. A 2018 National TB Patient Catastrophic Cost Survey revealed that 22% of non-MDR-TB and 45% of MDR-TB households experienced catastrophic costs, primarily due to income loss and non-medical expenses rather than direct medical fees. Low household income, stigma, and inpatient care were identified as key risk factors for financial hardship. Taiwan’s system of subsidies, reimbursement of copayments, and dedicated grants reflects its commitment to reducing financial barriers and ensuring equitable access to TB treatment.

Source: Chan, P.C., Chiang, C.Y., Lee, P.H., Lo, H.Y., Chu, P.W., Chen, J.J., Kato, S. and Raviglione, M.C.B., 2025. Assessing the impact of the TB response in Taiwan–the journey towards ending TB. IJTLD open, 2(5), pp.251-259.

Tuberculosis in Patients With Chronic Mental Illness N002

Patients with mental illness were found to have a significantly higher risk of developing tuberculosis (TB). To investigate this association, this study utilized the National Health Insurance Research Database (NHIRD), a nationally representative dataset in Taiwan, to assess TB incidence among patients with chronic psychiatric disorders—including schizophrenia, bipolar disorder, schizoaffective disorder, and major depressive disorder—compared to the general population. Patients diagnosed between 2002 and 2013 were identified through the Catastrophic Illness Registry, which ensures strict clinical verification and captures only severe and persistent mental illness cases. After excluding individuals with conditions such as type 1 diabetes, cirrhosis, cancer, dialysis, HIV, past TB, and amended diagnoses, a total of 162,377 subjects were included in the analysis. TB cases were defined using the Tuberculosis Database, which requires positive culture results, radiographic abnormalities, and diagnostic confirmation.

The study population consisted of 162,161 mental illness patients and 810,805 matched controls, with no significant baseline differences in sex, age, income, urbanization level, comorbidity index, or major comorbidities, confirming effective propensity score matching. Results showed consistently higher TB incidence in mental illness patients overall (87 vs. 71 per 100,000 person-years), across both sexes, and most age groups. The difference was particularly pronounced in those aged 65 years or older (278 vs. 195). TB incidence was also higher across nearly all income levels and urbanization strata, except for rural towns where rates were slightly lower in patients with mental illness. Importantly, the elevated TB incidence was observed regardless of the presence of type 2 diabetes mellitus or chronic kidney disease.

After adjusting for confounding variables, the conditional Cox proportional hazards model confirmed a 1.48-fold increased risk of TB among patients with mental illness (95% CI: 1.38–1.59). Additional risk factors included older age, which showed a steep increase in hazard ratios (HRs ranging from 1.86 for ages 20–34 to 21.82 for ≥65 relative to <20), and lower income, which was inversely associated with TB risk. Comorbidities such as type 2 diabetes (HR: 1.22) and chronic kidney disease (HR: 1.24) further heightened susceptibility. Cumulative incidence curves demonstrated a persistently higher rate of TB in the mental illness group compared with the general population, underscoring the need for targeted TB screening and preventive strategies for this vulnerable population.

Source: Hung, L.C., Kung, P.T., Tsai, T.H., Tsai, W.C. and Huang, K.H., 2025. Risk Assessment of Tuberculosis in Patients With Chronic Mental Illness and Related Factors: A Population‐Based Cohort Study in Taiwan. The Clinical Respiratory Journal, 19(6), p.e70088.

Adherence to Tuberculosis Infection Treatment and Tuberculosis Reactivation N001

A study hypothesized that higher adherence to latent tuberculosis infection (TBI) treatment would lower the risk of tuberculosis (TB) reactivation. Conducted in northern Taiwan, it evaluated treatment completion rates, factors influencing adherence, and their association with TB reactivation in a large patient cohort.

The retrospective analysis included de-identified clinical data collected between 2016 and 2021. Patients were 13 years or older, with either a TBI diagnosis or documented exposure to TB. The goal was to identify high-risk groups and determine how treatment adherence influenced TB prevention.

TBI was defined by diagnostic codes or positive IGRA results. Patients were categorized into four groups: non-initiation (N), incomplete treatment (IC), complete treatment (C), and a control group of TB contacts without IGRA positivity. Adherence above 90% was considered complete.

The final cohort included 1,432 patients: 378 in group N, 330 in IC, 430 in C, and 294 in controls. Over three years, TB developed in 34 patients (2.3%). Risks varied widely, from 6.1% in group N to just 0.5% in group C, showing a strong protective effect of treatment completion.

Patients in the non-initiation group were older and had higher rates of diabetes, chronic kidney disease, end-stage kidney disease, and active cancer. Significant differences in sex distribution, underweight status, smoking history, and HIV prevalence were also seen between groups.

Multivariable Cox regression confirmed that treatment reduced TB risk. Compared with group N, hazard ratios were 0.32 for IC and 0.05 for C. Each 10% increase in adherence lowered risk by about 23–24%. These results remained consistent even after accounting for death as a competing risk.

Overall, 67% of patients were prescribed TBI treatment, but only 38% completed it. Completion was strongly associated with protection against reactivation, underscoring the importance of initiating and finishing therapy, especially in high-risk populations. 

Source: Chien, Y.C., Chang, C.H., Shu, C.C., Wang, H.C. and Yu, C.J., 2025. Adherence to Tuberculosis Infection Treatment and its Impact on Prevention of Tuberculosis Reactivation: A Retrospective Cohort Study from Taiwan. Journal of Infection and Public Health, p.102917.