SMART PARTNERSHIP IN
DETECTING SPUTUM SMEAR
POSITIVE TUBERCULOSIS (TB) :
AN EXPERIENCE IN THE
DISTRICT OF BATU PAHAT
Linayanti R1, Arbaiah O1, Rashidah D1,
Mohd Asri Z1, Naimah I1, Noorhaida U2
1 Batu Pahat Health Office
2 Muar Health Office
INTRODUCTION
• Detection rate of smear positive Tuberculosis in Batu Pahat Johor, remains less than 70% over the last 5 years.
• The management feels that more aggressive approach must be introduced to the current situation.
• Involvement of the private practitioner plays an important role in TB detection and its management.
BATU PAHAT DISTRICT
3
Area: 1872.56 Km2
Population : 406 400
(2011)
Health Clinic: 15
District Hospital: 1
Private Hospital: 2
Private Clinic : 70
Trend of TB in Johor, 1990 - 2011
626
625
622
660
759
704 851
984
1009 1158
1215 1
366
1311 1422
1443
1407 1
553
1591
1700 1
854
2058
2038
30
29
29
29
33
29
34
39
39
43
44
50
45 4
8
48
45
49
49
54
53
61
61
22
22
21
19 2
2
19 21
25
24
28
27
29
24
25 26
26
28
27
29
27
30
29
0
10
20
30
40
50
60
70
0
500
1000
1500
2000
2500
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
No. of cases Incidence Rate Incidence rate (Sputum Positive)
Case Detection Rate by district, Johor, 2010-2011
69
44
51
62
66
38
54
80
57
43
60
70
55
50 51
64
40
52 55
36
52 55
0
10
20
30
40
50
60
70
80
90
JB MUAR BP KLUANG KT SEGAMAT PONTIAN MERSING KJ LEDANG JOHOR
CD
R %
District
2010 2011
OBJECTIVES
• General:
To increase the detection rate of smear positive TB in
Batu Pahat
Specifics:
• To increase detection rate of sputum smear
positive TB to 70%
• To improve the quality of sputum taken
• To increase sputum AFB screening of the new
outpatient cases to 2%
• To improve knowledge and awareness among
health staffs and community
METHODOLOGY
• A cross sectional study using self administered
questionnaire for health staff and community to
determine the knowledge and awareness of
Tuberculosis.
• 44 staffs and 100 individuals were recruited in the study
via random sampling.
• Retrospective review on sputum AFB data to analyze the
quality of the specimen.
• A cross sectional study among patients referred for
sputum AFB in Klinik Kesihatan Batu Pahat
METHODOLOGY
• The data were analyzed using SPSS version 15.0.
• Action research framework was applied to overcome the
problem by engaging the entire stakeholder involved in
TB management including private practitioners.
Group discussion
Stakeholder meeting Proposal presentation to the
stakeholders (10.8.11)
Addition to objectives and list of
activities.
Overall positive feedbacks from all
stakeholders.
AR group discussion (19.8.11)
• Brainstorming
• Reviewing secondary data and
literature review
• Survey questionnairre
Major Problems Identified
1. Low notification because of
low awareness among staff
and GP
2. Low Sputum Quality
because of lack of
knowledge among staff and patients
3. Low screening because of
lack of knowledge
and awareness
METHODOLOGY
Actions to overcome the problem:
Increasing the knowledge and awareness
TB alert card
Development of new health promotion materials
Infoblast
Workshops/trainings
Continuous Medical Education (CME)
Monitoring of adherence to standard procedure of
TB management
Implement three clinic days per week.
- 62.2% referred by
MO
- 66.7% was referred
for cough more than
7 days
- 15 (4.7%) smear
positive were
detected
Cross sectional study among patients referred for
sputum AFB in Klinik Kesihatan Batu Pahat , 2011
(n=320)
Knowledge and awareness of TB among
community (n=100)
58% have good knowledge on TB
The younger age group (<30 years old) have good
knowledge compared to others
Women have better knowledge compared to man
Most common source of TB information was from
newspaper, magazines and television
55% agreed that TB is a serious problem
97% knows that anybody can be infected by TB
55% do not know how TB can be cured
13% afraid of TB patient, 58% felt sorry for them
95% would like to know more about TB
Knowledge and awareness of TB among Health Staff
(n=44)
• 34.4% never attended TB course
• 47.7% never had no experience managing TB patient
• 47.7% unable to recognize TB
• 79.5% answered wrongly for the treatment of TB
• 84.1% did not know when to refer TB cases
• 75.5% did not know definition of DOTS
• 64.1% did not know the correct monitoring of TB patients
• 84.1% did not know how to prevent TB among healthcare worker
• Before • After
DAY CLINIC
AKTIVITY
MONDAY CONTACT
SCREENING
TUESDAY CONTACT
SCREENING
WEDNESDAY CHEST CLINIC
THURSDAY CONTACT
SCREENING
FRIDAY CHEST CLINIC
Change of clinic schedule
DAY CLINIC
AKTIVITY
MONDAY CONTACT
SCREENING
TUESDAY CHEST CLINIC
WEDNESDAY CHEST CLINIC
THURSDAY CHEST CLINIC
FRIDAY CONTACT
SCREENING
PPP U29
d/a Klinik Kesihatan Rengit
Tuan,
PERINGATAN : PERTAMA
LAPORAN PENCARIAN KES JANUARI 2012
Adalah saya dengan hormatnya merujuk kepada
perkara di atas.
Dukacitanya dimaklumkan bahawa Laporan
Pengesanan Awal Kes yang dijalankan oleh pihak
tuan melalui Klinik Kesihatan dari Bulan Januari
berdasarkan reten Jumlah Saringan AFB adalah
1.1% berbanding jumlah sasaran yang ditetapkan
iaitu 2% .
Sehubungan dengan itu, pihak tuan diarahkan
untuk meningkatkan pencapaian di Klinik Kesihatan
masing-masing. Surat peringatan Kali Kedua
akan menyusul beserta surat tunjuk sebab
sekiranya pencapaian yang telah ditetapkan masih
tiada perubahan.
Kerjasama dan keprihatinan pihak tuan di dalam
perkara ini amat dihargai.
Sekian, terima kasih.
Reminder letter
Percentage of TB cases, Batu Pahat Johor 2008 - 2012
55.1 64.5
54 50 57.7
33.3 23.5
36 35.2
32
11.6 12 10 14.8 10.3
0
10
20
30
40
50
60
70
80
90
100
2008 2009 2010 2011 2012(Jan-April)
Pe
rce
nta
ge
of T
B c
ase
s
Smear positive Smear negative Extrapulmonary
Incidence rate of TB, Batu Pahat Johor,
Jan- April 2008 - 2012
7.4
6.05
7.2
9.3
11.07
0
2
4
6
8
10
12
2008 2009 2010 2011 2012
Incid
en
ce /100 0
00 p
op
ula
tio
n
Year
14.8
12.1
14.4
18.6
22.2
0
5
10
15
20
25
2008 2009 2010 2011 2012
CD
R (
%)
Year
Case detection rate, Batu Pahat Johor,
Jan – April ,2008 - 2012
Results
• CDR:
– Detection rate of smear positive Tuberculosis was
22.2% as compared to 18.6% during the same period
in 2011.
• Unsatisfactory sputum specimens:
– Reduced from 39.3% (2011) to 34.5% (2012)
Source of notification for TB cases, Batu Pahat Johor,
2008 - 2012
38.4 41.5 40.5 32.2
25.6
42 44
40 46.6
48.8
19.6 14.5 19.5 21.2 25.6
0
10
20
30
40
50
60
70
80
90
100
2008 2009 2010 2011 2012 (Jan-
April)
Perc
en
tag
e
Year Health Clinic Hospital Private
Percentage of sputum AFB screening of the new outpatient
cases in health clinic, Batu Pahat, 2007 – 2012 (Jan - April)
2.23
1.7 1.9
2.3
2.04 2.06
0
0.5
1
1.5
2
2.5
2007 2008 2009 2010 2011 2012
Perc
en
t of
patien
t scre
en
ed
Year
Detection of new TB cases from GP alert card
Year No. of cases
referred
No. of confirmed
cases
2011 71 1 (1.4%)
2012
(Jan-April)
15 2 (13.3%)
Level of Knowledge on TB management among health
staff, Batu Pahat, 2012
4.5
43.2
52.3
40.9
50
0 0
10
20
30
40
50
60
Good Satisfactory Poor
Pe
rce
nta
ge
of
sta
ff
Level of knowledge
Pre intervention Post intervention
CONCLUSION
• Participatory action of all members of
stakeholders in Action Research methodology is
a good approach to overcome problem of low
detection rate of smear positive Tuberculosis in
Batu Pahat District.
• Detection rate increased to 22.2% from 18.6%
REFERENCES
• Ministry of Health Malaysia, 2002, Practice Guideline for the Control and
Management of Tuberculosis
• Ministry of Health Malaysia, 2002, National Tuberculosis Information System – TBIS Manual
• Noriah B et al, 2010, Action Research: Trainer’s Guide
• Batu Pahat Health Office, 2010, Annual Report
• Batu Pahat Health Office, 2011, Annual Report
• World Health Organization, 2011, Global Tuberculosis Control
• Aziah A.M, 2004, Tuberculosis in Malaysia: Combating the Old Nemesis,
Medical Journal Malaysia 59 : 1-3
Number of TB cases in Batu Pahat Johor , 2003 - 2012
86 76
106 109 118
45 39
46 41
72
83
25
11 16 19 19
35
8
136 138
166
200
236
78
0
50
100
150
200
250
2007 2008 2009 2010 2011 2012 (Jan - April)
Nu
mb
er
of
TB
ca
se
s
Year
Smear positive Smear negative Extrapulmonary All TB cases
Incidence of TB, Batu Pahat, 2008 - 2012
0
10
20
30
40
50
60
2008 2009 2010 2011 2012(Jan-April)
Inc
ide
nc
e /1
00
00
0 p
op
ula
tio
n
Smear positive Smear Negative Extrapulmonary All cases
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