Strengthening health systems to improve tuberculosis (TB) contact investigation and preventive treatment in Mimika, Indonesia

  • Trisasi Lestari

    Student thesis: Doctor of Philosophy (PhD) - CDU


    Tuberculosis (TB) remains a major global health problem. It is among the top ten leading causes
    of death in low and lower-middle-income countries. Yet TB can be prevented and can be cured.
    The strategy to eliminate tuberculosis emphasises TB prevention and research to optimise
    implementation. A key TB prevention activity comprises contact investigation and preventive
    treatment for high-risk contacts.

    This study aims to conduct implementation research that evaluates the impact and challenges of
    health systems strengthening including decentralisation of services, to improve detection,
    treatment and prevention of tuberculosis in Mimika district, Papua province, Indonesia. Mimika
    district is a remote and resource-limited district of Indonesia with a total population of 201,677
    in 2017 and notified TB incidence of 743 per 100,000 population. A package of interventions to
    facilitate the adoption of TB contact investigation and preventive treatment was initiated in
    September 2017, and outcomes and impacts were followed-up until December 2021.
    Baseline data on key performance indicators were obtained for 2014-2017, and data during study
    implementation are reported in this thesis for 2018-2021. Commencing prior to study
    implementation, district TB data between 2014 and 2021 revealed a steady increase in TB case
    finding in Mimika district from 920 in 2014 to 1796 in 2019. An 18.6% drop to 1461 then occurred
    during the COVID-19 pandemic in 2020, but rapidly rebounded in 2021. The TB program in
    Mimika, where intensive health system strengthening activities had been underway, was less
    impacted by COVID than other parts of Indonesia and demonstrated good early recovery. The
    introduction and expansion of GeneXpert MTB/RIF increased the detection of drug-resistant TB
    case finding from only 12 cases in four years (2014-2017) to 31 cases per year on average. The
    main study activity was implementation of contact investigation. The number of contact
    investigations conducted increased significantly from only 11 cases before the intervention’s
    commencement in 2017 to 564 cases in 2020. The largest change in the coverage of contact
    investigation was among HIV-negative index cases, which grew from 1.4% in 2016 to 74.6% in
    2021. A total of 9081 contacts were investigated, and 216 were with TB, resulting in a total yield of 2.4%.
    During the study, 662 children, or half the eligible child contacts aged <5 years between
    2016-2021, commenced TPT and 418 completed 6 months of TPT.
    The main conclusion from this thesis is that improvements in major TB programmatic indicators
    can be achieved in a resource-limited setting in Indonesia. Increased TB case notifications -
    including drug resistant TB notifications - as well as program indicators of contact investigation
    for active case finding and coverage of TB preventive treatment, were all seen. These have been
    achieved under programmatic conditions without major investment in resources while
    maintaining treatment outcomes, and despite major disruptions to services due to the COVID
    Date of Award2024
    Original languageEnglish
    SupervisorAnna Ralph (Supervisor) & Stephen Graham (Supervisor)

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