International Journal of Medicine, Health and Food Sciences ISSN : 2581-2963 Volume 1, Issue 2 2017 www.doarj.org CONTRIBUTING FACTOR WHICH INFLUENCE THE SUCCESS OF TUBERCULOSIS TREATMENT ON CHILDREN UNDER FIVE IN THE TIMOR TENGAH SELATAN REGENCY Maria Agnes Etty Dedy 1, Pius Weraman 2, Hari Rarindo 2, and Rafael Paun 3 1 Lecturer Faculty of Medicine, University of Nusa Cendana Kupang 2 Lecturers Faculty of Public Health and Public Health Sciences Program of Postgraduate Program, University of Nusa Cendana Kupang 3 Lecturers Public Health Science Program Post Graduate Program Nusa Cendana University of Kupang and Nursing Department Health Polytechnic Department of Health Kupang Email correspondence: maria.agnesed@gmail.com Abstract: Children under five with malnutrition likely to be more susceptible to TB because of damage to the cells of Cell Mediated Immunity (CMI) as a result of malnutrition itself. The success of treatment against TB is one among other indicators to control morbidity and mortality rates due to TB incidence on children under five. From the pharmacokinetics aspect, the protein plasma binding determines amount of drug that can reach out the receptor. On the children under five with malnutrition who suffer from TB, the amount of protein is less; therefore, it will be only slightly active drug substance which can bind to proteins of blood plasma. The kind of research used was observational analytic with case-control design. The research was conducted in the Timor Tengah Selatan (TTS) District with total samples were 72 respondents. The determinant for the success of treatment was the children under five suffering from TB without malnutrition complication risk were likely to succeed in treatment at 14,154 times greater, compared to the children under five with malnutrition complications. It is recommended that the TTS District government needs to enforce a regulation which aims to raise awareness and foster a sense of all parties towards the high incidence of malnutrition over the district area, given that is is an indirect cause which will trigger the emergence of other diseases, as well as minimize the chances for success of a treatment. This study is expected to be as a basis for dose adjustment in order to increase the chances of the success of TB treatment on children under five. Keywords: Children under five TB, success treatment, malnutrition, TTS District I. INTRODUCTION A large tuberculosis (TB) burden accounted for 15-20% of total TB cases in children, whereas at low burden it is estimated that 2-7% of total TB cases in children. (1) Tuberculosis (TB) has infected about a third of the world's population, and an estimated 8.8 million new TB cases occurred in 2005, with the concentration of cases being in poor countries. A total of 1.6 million of whom died of TB. (2) The results of the WHO study with the Center for Disease Control and Prevention, the United Nations of Children and Education Federation (UNICEF), the International Union Against Tuberculosis and Lung Disease, the Treatment Action Group (TAG), the Stop TB Partnership and USAID published in October 2013 that one of the factors causing a child to get TB is a susceptible immune system, being infant, HIV-infected, or malnourished, is the group most at risk of falling ill or dying of TB. (3) 43 www.doarj.org
The proportion of TB cases among all TB cases in Indonesia in 2012 reached 8.2%, while NTT province was 6.8%. The proportion of child TB cases among all TB treated cases varies considerably at the provincial, district/city level to health care facilities. (4) Data 2014 from TB Managers in the Communicable Disease Control Section, South Timor Tengah District mentioned that there are 33 children (aged less than 14 years) who have TB in this district throughout 2014. (5) UNICEF Conceptual Framework (1992) identifies that infectious diseases are a direct cause of malnutrition in infants, in addition to adequate food availability. In general, the relationship between TB and malnutrition has long been known. TB worsens the condition of a person suffering from malnutrition and poor nutrition weakens one's immunity. (6) From the pharmacokinetic aspect of the drug, in the process of drug adsorption, in order to reach the prescription (workplace) of the drug, the drug must bind to the blood plasma protein. In children with malnutrition status, where protein deficiency, plasma concentrations lower than normal plasma impact on the reduced drug concentrations that can be bound by protein (protein binding) which would be more difficult to achieve the desired effect (therapeutic effect). Drugs released from plasma proteins will of course be distributed in volume distribution so that the increase in the number of unbound drugs in the body by 5%. In addition, when the number of unbound drugs in the plasma increases, the elimination rate will increase (if the drug clearance is not unchanged). Thus, when plasma drug concentrations are lower than normal then free drug concentrations become larger which can lead to toxicity in the blood. In children under five with a small volume of distribution will result in greater toxicity because the number of solvents (blood) is also less. (7) The objectives of this study were to identify and analyze internal and external factors related to the occurrence of TB of children under five in TTS District, internal and external risk factors for TB infants in TTS District and to analyze the chances of recovery or the chance to succeed in the treatment of TB children with complications and without complications of malnutrition. II. RESEARCH METHODOLOGY This research uses observational analytic method with sampling technique using total sampling. The sample of this research is 72 children under five who suffer from TB with complication of malnutrition (case group) and without malnutrition (control group). Respondents for the case group were obtained from CWS NGO managing malnourished children who had been treated from 2003-2014, while the control group was obtained from TB management data at TTS District Health Office which then re-checked the medical record data of puskesmas, hospital and center health services in TTS District. The samples were then limited by inclusion and exclusion criteria in both case and control groups. (8)(9)(10)(11)(12) The independent variables were 26 variables divided into internal factors (1) birth weight status (LBW), (2) history of BCG immunization, (3) history of vitamin A release, (4) presence or absence of comorbidities, (5) (2) monthly earnings from respondents' parents, (3) regular medicine taking, (4) family support in drug delivery, (5) access to (7) daily food intake, (8) TB toddler relationship with contact source, (9) the presence of 44 www.doarj.org
a household source of contact, (10) the source of unfamiliar contact, ( 11) the source of contact discards sputum, (12) feeding utensils together, (13) the sou rce of contact keeping and playing with the child, (14) the source of sleep contact with the child, (15) the length of contact, (16) the way cough, (17) frequency of recurrence, (18) house floor type, (19) ventilation, (20) lighting, (21) humidity, and (22 ) occupancy density). Dependent variables are TB children with severe malnutrition complication and no complication of malnutrition and success of TB treatment of children under five with complication of malnutrition and without complication of malnutrition. The analysis technique used is chi square analysis to see the relationship and risk factor (OR). Furthermore, a logistic regression analysis test is used to estimate the probability of TB occurrence in children under five with complication of malnutrition and without complication of malnutrition. III. RESULT The following table summarizes the results of this study: Table 1. P and OR values based on chi-square analysis No. Risk factors The value of P OR Description Internal risk factors 1. LBW status 0.000 6.818 Significant 2. History of BCG immunization 0.674 0.471 Not significant 3. Provision of vitamin A 0.674 0.647 Not significant 4. The presence or absence of comorbidities 0.000 10.000 Significant 5. Recurrence frequency 0.000 14.154 Significant External risk factors 6. Smoking habits in respondents' parents 0.053 2.600 Not significant 7. Monthly income of respondent's parents 0.013 10.000 Significant 8. Regularity of taking medication of 0.020 3.572 Significant respondents 9. Family support in drug delivery 0.001 8.800 Significant 10. Access to health facilities 0.012 3.707 Significant 11. Parenting 0.125 0.449 Not significant 12. Daily food intake 1.000 1.000 Not significant 13. The relationship of children under five with 0.004 4.375 Significant the source of contact 14. The presence or absence of a home contact 0.032 2.841 Significant source 15. The presence or absence of contact sources is 0.053 0.385 Not significant not at home 16. The way contact sources throw sputum 0.555 0.486 Not significant 17. Tableware to drink together 0.053 2.600 Not significant 18. The source of contact keeps and plays with the child 0.772 0.845 Not significant 45 www.doarj.org
19. Sources of sleep contact with toddlers 0.031 2.906 Significant 20. Length of contact 0.173 0.377 Not significant 21. How to cough 0.394 0.471 Not significant 22. Type of floor of the house 0.743 0.806 Not significant 23. Ventilation 0.691 0.727 Not significant 24. Lighting 0.629 1.264 Not significant 25. Humidity 0.023 4.000 Significant 26. Dwelling density 1.000 1.000 Not significant Table 2. Value of P and OR based on logistic regression analysis No. Variables P OR Description Internal risk factors 1. BBLR status 0.041 2.800 Significant 2. Complicated disease 0.000 12.000 Significant External risk factors 3. Family support in drug delivery 0.036 3.180 Significant 4. The relationship of children under five Significant 0.028 3.348 with the source of contact 5. Access to faskes 0.012 3.769 Significant IV. 6. Regularity of taking medicine 0.008 4.295 Significant 7. Sources of sleep contact with toddlers 0.003 4.675 Significant 8. Source of home contact 0.001 8.625 Significant 9. Earnings per month 0.999 0.600 Not significant 10. Recurrence frequency 0.999 0.600 Not significant 11. Humidity 0.031 5.645 Significant DISCUSSION 1.1 Internal Risk Factors Children born with a history of LBW had a risk of getting TB 2.800 times greater than children born not with LBW status. Children with LBW are at greater risk for malnutrition. (12) If children under five become malnourished patients will be more likely to become TB patients due to destruction of cellular immune cells that become the body's defense against TB germs. (13)(14)(15)(16) Toddlers with other co-morbidities are at risk of getting TB 12,000 times more than children under five who do not have other comorbidities. Companion disease can decrease a person's immunity from illness especially when the disease is a disease associated with inflammatory processes such as diarrhea. If a person's immunity is weak then the food that enters the body that should be metabolized for the body's nutritional needs is used to fight the germs that cause disease. 1.2 External Risk Factors Family support in drug delivery with the incidence of TB in children under five is a risk 46 www.doarj.org
factor. Families who are not supportive in giving the drug to respondents make the respondents at risk of 3.180 times greater for TB than respondent families who support in giving drugs. WHO has recommended the Directly Observed Treatment Short Course (DOTS) strategy as a strategy in TB control since 1995. The World Bank states that the DOTS strategy is one of the most effective health interventions. Integration into basic health services is strongly recommended for efficiency and effectiveness. (22) Family support in the delivery of TB drugs for infants with TB is essential as one form of PMO in TB treatment. With regard to the relationship of children under five with a source of contact, people who have close relationships with the source of contact will have a risk of exposure that is more often due to the intensity of the relationship itself. The closer the relationship with the patient will increase the risk of contact, the close relationship between the patient and the contact can affect the possibility of infection (Sularso, 1994). (23) Toddlers with parents or close relatives who have TB are at risk for TB 3.348 times greater than toddlers who are related to a near-distant TB patient (distant relative). Access to health facilities with TB incidence is a risk factor. Respondents who had access to unhealthy health facilities had a risk of 3,769 times greater for TB than those who had access to health facilities. In that context, the distribution of health facilities both in the village and in the city should be done equally. Health facilities should be made by the government to improve the health status of the community. Drug regularity is a risk factor for TB occurrence in children under five in TTS District. Respondents who did not take medication regularly had a risk of getting TB 4.295 times more than respondents who took medication regularly. In the incidence of TB of children under five, the regularity of taking medication is determined by the Drug Supervisor (PMO). Irregular treatment and incomplete combinations are thought to have resulted in double immunity of TB germs against OAT. The relationship between the sources of home contact with the incidence of TB in children under five and the presence or absence of sources of home contact is a risk factor. Respondents who had a source of adult domestic TB contact had a risk of 8.625 times more likely to get TB than people who did not have a source of adult TB contact. People living in homes with tuberculosis patients are 42 times more likely to have TB BTA (+) disease than people who do not live in a home with a transmitting source. A study conducted in Surakarta in 1991 found that the risk of people who had had contact with suspected tuberculosis contracted tuberculosis 3.22 times greater than people who had never been in contact with suspected tuberculosis (Vesitaria, 2011). (24) There is a relationship between house moisture with the incidence of TB in children under five. This is consistent with the results of a study conducted by Vesitaria (2011), in which a person who has a home with a TMS moisture (<70%) is 5 times more likely to live in a house with an MS moisture ( 70%). Wet house conditions are ideal for the proliferation of germs that affect the transmission of disease. (28) 47 www.doarj.org
Based on the results of the Odd Ratio (OR) analysis using logistic regression, under-five children with TB without complications of malnutrition have a chance to succeed in treatment as much as 14,154 times greater than children under five without TBS complication. This is due to the plasma proteins present in the blood of infants without tuberculosis complications higher than those with TB with severe malnutrition complications so that the drug's active substances can be bound by protein (protein binding) and brought to the drug receptor. In addition, risk factors do not recur frequently, regular drug administration, easy access to health facilities and adherence to treatment also increase the chances of respondents to succeed in TB treatment. V. CONCLUSION Based on the results of research and discussion of the previous chapter can be concluded as follows. 1. There are 9 factors (2 internal factors: LBW status, and presence or absence of comorbidities, and 7 external factors: family support in drug delivery, toddler relationship with source of contact, access to access, regular medication, income per month of respondent's parents, and humidity) are significantly related and a risk factor with the incidence of TB in children under five in TTS District. 2. Children with no complications of TB malnutrition have the opportunity to be successful in the treatment of 14.154 times greater than children under five suffering from tuberculosis with malnutrition complications. VI. RECOMMENDATIONS 1. For the local government of TTS District, it is necessary to create a local sensitive community health program to be able to arouse all parties in order to grow a sense of concern for the high number of malnutrition cases in TTS District because malnutrition is the indirect cause of the emergence of other diseases as well as small opportunities to be successful in treatment. 2. For health practitioners and other concerned parties, the results of this study are expected to be the basis for making dose adjustments to increase the chances of success of TB treatment of children under five. 3. For other researchers, the results of the study are expected to be the basis for further research in the field of bimolecular in order to obtain clinical data on an evidence base for the results of this study more applicable. ACKNOWLEDGEMENTS 1. Director of Post Graduate, Head of Public Health Study Program and lecturers at Post-Graduate Program of Nusa Cendana University for the opportunity of Waste Science given. 2. To Dr. Rafael Paun., S. KM., M. Kes for his critical input. 3. Non-Governmental Organization, Church World Service, So'e City, TTS District, East Nusa 48 www.doarj.org
Tenggara Province with their permission and permission to provide data, facilitate and cooperation during this research. Also to the Health Office, community health centers and hospitals/clinics in TTS District for mentoring and facilitation provided. Finally, to all respondents and parents of respondents who are willing to be an important part of this research. REFERENCES 1. World Health Organization. Global Global Plan To Stop TB 2011-2012. Geneva; 2010. 2. World Helath Organization. TB and Nutrition. Geneva; 2012. 3. World Helath Organization. Combating Tuberculosis in Children. Geneva; 2013. 4. Ditjen PP dan PL Kementrian Kesehatan. TB Anak [Internet]. 2015 [cited 2015 Jan 25]. Available from: www.tbindonesia.or.id/tb-anak/ 5. Dinas Kesehatan Provinsi NTT. Data Dinas Kesehatan NTT. Kupang; 2014. 6. Unicef Nations Children s Fund. Conceptual Framework. Amerika Serikat; 1992. 7. Katzung BG. Farmakologi Dasar dan Klinik. 10th ed. Jakarta: ECG; 2010. 8. Arikunto S. Prosedur Penelitian Sebuah Pendekata Praktik. Jakarta: Renika Cipta; 2013. 9. Nasir M. Metode Penelitian. Bogor: Ghalia Indonesia; 2009. 10. Notoatmodjo S. Metode Penelitian Kesehatan. Jakarta: Renika Cipta; 2012. 11. Nastiti RN, Supriyanto B, Setyanto DB. Buku Ajar Respirologi Anak. Jakarta: IDAI; 2012. 12. USAID FROM THE AMERICAN PEOPLE. Nutirtion and Tuberculosis. 2010; 13. Yulistyaningrum, Rejeki DSS. Hubungan Riwayat Kontak Penderita Tuberkulosis Paru (TB) Dengan Kejadian TB Anak Di Balai Pengobatan Penyakit Paru-Paru (BP4) Purwokerto. 2010;43 8. 14. Saryono, Anggreani. Metodologi Penelitian Kualitatif dan Kuantitatif dalam bidang Kesehatan. Yogyakarta: Nuha Medika; 2013. 15. Widoyoko EP. Teknik Penyusunan Instrumen Penelitian. Yogyakarta: Pustaka Pelajar; 2013. 16. Notoatmodjo S. Metodologi Penelitian Kesehatan. 1st ed. Jakarta: PT Rineka Cipta; 2010. 17. Murniasih, Liviana. Jurnal Kesehatan Surya Medika Yogyakarta Hubungan Pemberian Imunisasi Bcg Dengan Kejadian Tuberkulosis Paru Ada Anak Balita Di Balai Pengobatan Penyakit Paru-Paru Ambarawa Tahun 2007. Yogyakarta: Surya Medika; 2007. 18. Pakasi TA, Karyad E, Dolmans W, Meer J Van der, Velden K Van der. Malnutrition and socio-demographic factors associated with pulmonary tuberculosis ini Timor and Rote Islands, Indonesia. J Int Tuberc Lung Dis. 2009; 19. Lettow M van, Harries AD, Kumwenda JJ, Zijlstra EE, Clark TD, Taha TE, et al. Micronutrient malnutrition and wasting in adults with pulmonary tuberculosis with and 49 www.doarj.org
without HIV co-infection in Malawi. BMC Infect Dis [Internet]. 2004; Available from: http://www.biomedcentral.com/1471-2334/4/61# 20. Karyadi E. Cytokines Related to Nutritional Status in Patients With Untreated Pulmonary Tuberculosis in Indonesia. Asia pac J Clin Nutr. 2007;2018 226. 21. Fitriani E. Faktor Risiko Yang Berhubungan Dengan Kejadian Tuberkulosis Paru. Unnes J Public Heal. 2013; 22. Departemen Kesehatan RI. Pedoman Nasional Penanggulangan Tuberkulosis. Jakarta; 2007. 23. Sularso K. Studi kasus kontrol faktor risiko dari TB Paru di Kotamadya Surakarta. Universitas Indonesia; 1991. 24. Vesitaria, Kusnoputranto. Tuberkulosis Paru di Palembang, Sumatera Selatan. J Kesehat Masy Univ Indones. 2011; 25. Apriani W. Faktor-faktor yang Berhubungan dengan Kejadian TB Paru di Kabupaten Donggala Provinsi Sulawesi Tengah. Universitas Indonesia; 2001. 26. Mahpudin AH, Mahkota R. Faktor Lingkungan Fisik Rumah, Respon Biologis dan Kejadian TBC Paru di Indonesia. J Kesehat Masy Nas. 2001; 27. Simbolon D. Faktor Risiko Tuberculosis Paru di Kabupaten Rejang Lebong. J Kesehat Masy Univ Indones. 2007; 28. Departemen Kesehatan RI. Pedoman Sanitasi Rumah Sakit Di Indonesia. Jakarta; 2002. 50 www.doarj.org