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As Indonesia’s rifampin resistance testing rates are lower than global testing rates per the 2020 WHO global tuberculosis (TB) report, prevalence of multidrug-resistant TB may be underestimated. Our study aimed to evaluate prevalence and patterns of TB drug resistance (DR) within Indonesia. We conducted a cross-sectional analysis of baseline data collected from 2017–2018 as part of a cohort study of adults with presumed pulmonary TB at 7 DR-TB referral hospitals in Indonesia. Bacteriological examinations (acid-fast bacilli, GeneXpert, sputum culture) and drug-susceptibility testing were performed following the guidelines of the National TB Program. Of 447 participants with complete bacteriological examinations, 312 (69.8%) had positive sputum cultures for Mycobacterium tuberculosis. The proportion of MDR and pre-extensively drug-resistant was higher in previously treated compared with newly diagnosed participants (52.5% [73/139] versus 15% [26/173]). Compared with drug-sensitive case, drug-resistant TB was associated with cavities. Given the difference between rates of DR in TB referral hospitals from our study compared with the WHO survey in 2019 that showed 17.7% and 3.3% DR among previously treated and newly diagnosed participants globally, further characterization of Indonesia’s TB epidemiology in the general population is needed. Strategies, including public policies to optimize case finding, strengthen capacity for resistance testing, and prevent loss to follow-up will be critical to reduce the burden of TB in Indonesia.

Birth during pollen seasons may influence food allergy risk but no study has assessed pollen exposure. Using the HealthNuts population-based cohort of 5276 infants, we assessed grass pollen exposures, in utero and up to the first 6 months of life, on hen's egg, sesame and peanut allergy outcomes at 12 months. Cumulative pollen exposure in the first 7 days of life increased risk of peanut sensitization aMOR (adjusted multinomial odds ratio) = 1.21 (95% CI: 1.01-1.44). Exposure between first 4-6 months of life increased risk of hen's egg aMOR = 1.02 (95% CI: 1.004-1.04) and sensitization to all foods aMOR = 1.02 (95% CI: 1.003-1.04). Grass pollen exposure was associated with food challenge diagnosed food allergy, but only among infants with a maternal history of food allergy. Exposure to grass pollen in the intrauterine period and infancy may be important but more studies are needed to replicate these findings.

Supplemental material, sj-pdf-1-aar-10.1177_21526567211010728 for Community Response to the Impact of Thunderstorm Asthma Using Smart Technology by Ala AlQuran MPH Mehak Batra MDS Susanto Harry Nugroho PhD Anne E. Holland PhD Janet M. Davies PhD in Allergy & Rhinology

BackgroundThe most severe thunderstorm asthma (TA) event occurred in Melbourne on the 21st November 2016 and during this period, daily pollen information was available and accessible on smart devices via an App. An integrated survey within the App allows users to self-report symptoms.ObjectiveTo explore patterns of symptom survey results during the period when the TA event occurred.MethodsSymptom data from the Melbourne Pollen Count and Forecast App related to asthma history, hay fever symptoms, and medication use was explored. A one-week control period before and after the event was considered. Chi-square tests and logistic regression were used to assess associations between sex, age, symptoms, and medication use.ResultsOf the 28,655 responses, during the 2016 pollen season, younger (18 to 40 years) males, with no hay fever and no asthma were the most single and regular responders. During the TA event for new users, sex was only significantly associated with hay fever ( p = 0.008) of which 60.2% of females’ responses reported having hay fever, while 43% of males’ responses did not. Those with mild symptoms peaked during the TA event.ConclusionsMany individuals completed the survey on the app for the first time during the TA event indicating the potential of digital technologies to be used as indicators of health risk among populations at risk of TA events.

Birth during pollen seasons may influence food allergy risk but no study has assessed pollen exposure. Using the HealthNuts population-based cohort of 5276 infants, we assessed grass pollen exposures

Background The world's most catastrophic and deadly thunderstorm asthma epidemic struck Melbourne, Australia, on November 21, 2016. Objective Among thunderstorm-affected patients presenting to emergency rooms (ERs), we investigated risk factors predicting severe attacks requiring admission to hospital. Methods Thunderstorm-affected patients were identified from ER records at the eight major Melbourne health services and interviewed by telephone. Risk factors for hospital admission were analyzed. Results We interviewed 1435/2248 (64%) of thunderstorm-affected patients, of whom 164 (11.4%) required hospital admission. Overall, rhinitis was present in 87%, and current asthma was present in 28%. Odds for hospital admission were higher with increasing age (odds ratio 1.010, 95% CI 1.002, 1.019) and among individuals with current asthma (adjusted odds ratio [aOR] 1.87, 95% CI 1.26, 2.78). Prior hospitalization for asthma in the previous 12 months further increased the odds for hospital admission (aOR 3.16, 95% CI 1.63, 6.12). Among patients of Asian ethnicity, the odds for hospital admission were lower than for non-Asian patients (aOR 0.59, 95% CI 0.38, 0.94), but higher if born in Australia (OR = 5.42, 95% CI 1.56, 18.83). Conclusions In epidemic thunderstorm asthma patients who presented to the ER, higher odds for hospital admission among patients with known asthma were further amplified by recent asthma admission, highlighting the vulnerability conferred by suboptimal disease control. Odds for hospital admission were lower in Asian patients born overseas, but higher in Asian patients born locally, than in non-Asian patients; these observations suggest susceptibility to severe thunderstorm asthma may be enhanced by gene-environment interactions.

Background: A multidisciplinary collaboration investigated the world's largest, most catastrophic epidemic thunderstorm asthma event that took place in Melbourne, Australia, on Nov 21, 2016, to inform mechanisms and preventive strategies. Methods: Meteorological and airborne pollen data, satellite-derived vegetation index, ambulance callouts, emergency department presentations, and data on hospital admissions for Nov 21, 2016, as well as leading up to and following the event were collected between Nov 21, 2016, and March 31, 2017, and analysed. We contacted patients who presented during the epidemic thunderstorm asthma event at eight metropolitan health services (each including up to three hospitals) via telephone questionnaire to determine patient characteristics, and investigated outcomes of intensive care unit (ICU) admissions. Findings: Grass pollen concentrations on Nov 21, 2016, were extremely high (>100 grains/m 3 ). At 1800 AEDT, a gust front crossed Melbourne, plunging temperatures 10°C, raising humidity above 70%, and concentrating particulate matter. Within 30 h, there were 3365 (672%) excess respiratory-related presentations to emergency departments, and 476 (992%) excess asthma-related admissions to hospital, especially individuals of Indian or Sri Lankan birth (10% vs 1%, p

Background Elevated cord blood IgE is important on the pathway to allergic disease. The association between season of birth and infant cord blood IgE is not well-established. Study findings differ on which birth season is associated with higher cord blood IgE risk and its magnitude. We conducted a systematic review and meta-analysis of studies on season of birth and cord blood IgE. Methods We searched Medline, Web of Science, Scopus and ProQuest Health databases, and reviewed reference lists of articles that met the inclusion criteria. All included studies measured IgE as a binary variable using various cut-off values. We performed multivariate-random-effects meta-analysis to handle an exposure with multiple categories of Season of Birth. Results Our search identified 275 records and 10 had sufficient data to be included in a meta-analysis. Relative to summer, winter birth had the greatest odds of high IgE (≥ 0.1 IU/ml), meta-analysis OR = 1.24 (95%CI: 1.01–1.52). A similar OR, was found for IgE ≥ 0.5 IU/ml, OR = 1.30 (95%CI: 0.99–1.71). Conclusions A winter season of birth was associated with statistically significant higher odds of elevated cord blood IgE at cut-off ≥ 0.1 IU/ml but borderline at cut-off ≥ 0.5 IU/ml. This winter effect is likely to be a marker for a range of other environmental exposures during specific stages of pregnancy, such as aeroallergen exposures, maternal infections and vitamin D levels. Further research is required to support our finding and to identify the exact mechanisms that lead to the winter season of birth effect on circulating IgE levels, as this may have implications for allergic disease prevention.

Introduction It is unknown if high concentration of airborne grass pollen, where subtropical grasses (Chloridoideae and Panicoideae) dominate, is a risk factor for respiratory health. Here we systematically reviewed the association between airborne grass pollen exposure and asthma emergency department (ED) presentations and hospital admissions in subtropical climates. Objectives A systematic review was performed to identify and summarise studies that reported on respiratory health (asthma ED presentations and hospital admissions) and airborne grass pollen exposure in subtropical climates. Methods Searches were conducted in: MEDLINE, Web of Science, Scopus, CINAHL (EBSCO), Embase and Google Scholar databases (1966–2019). Risk of bias was assessed using a validated quality assessment tool. A meta-analysis was planned, however due to the heterogeneity in study design it was determined inappropriate and instead a narrative synthesis was undertaken. Results Nineteen studies were identified for inclusion, with a total of 598,931 asthma ED presentation participants and 36,504 asthma hospital admission participants in six countries (Australia, India, Israel, Italy, Spain, USA). The narrative synthesis found airborne grass pollen appears to have a small and inconsistent increase on asthma ED presentations (judged as: probably little effect n = 5, may have little effect n = 4, no effect n = 2 and uncertain if there is an effect n = 4) and hospital admissions (judged as: probably increase slightly n = 2 probably little effect n = 1, may have a little effect n = 1, no effect n = 3 and we are uncertain if there is an effect n = 4) in the subtropics. Furthermore, the reported effect sizes were small and its clinical relevance may be difficult to discern. Conclusion Exposure to airborne grass pollen appears to have a small and inconsistent increase on asthma ED presentations and hospital admissions in the subtropics. These findings are comparable to reported observations from studies undertaken in temperate regions.

Multi-drug resistant Tuberculosis (MDR-TB) remains big problem worldwide and it get worse since increasing number of primary DR-TB, in Indonesia from 1.2% in 2006 and now 1,8%. The use of rapid molecular test fasten diagnosis of DR-TB, but it has not yet been distributed in all provider. Therefore we need other predictor such as radiological findings. Studies found difference radiological appearance between drug-susceptible TB (DS-TB) and DR TB. Here we evaluate radiologic appearance as a prediction tool of DR TB especially among primary case. This report was part of a multicenter study titled Tuberculosis Research of INA-RESPOND on Drug Resistance (TRIPOD). We determined DR-TB using Xpert MTB/Rif and drug susceptibility test with Ogawa or MGIT and baseline CXR for radiologic appearance. Ethical clearance has been approved by NIHRD of MoH. There were 297 subjects with average age were 40 years old, mostly were male (61%), 160 (54%) primary TB, and almost half of them were DR-TB (49%). About 35% of DR-TB were primary cases. Radiologic appearance showed that DR-TB cases had cavity more than DS-TB (63.3% vs 37.3%, p Radiologic appearance among DR-TB tend to be more severe with cavity and wider lung affected.

BACKGROUND: Early life factors are associated with allergic respiratory diseases, but the role of high grass pollen concentrations during pregnancy and shortly after birth is not known. OBJECTIVE: To assess outdoor levels of grass pollen during the intrauterine period and at birth during peak pollen season on cord blood IgE in birth cohorts. METHODS: Three birth cohorts were included: MACS (n = 429), Australia; COPSAC (n = 200), Denmark; and LISA (n = 1968), Germany. Cord blood IgE was categorized (1 kU/L) and dichotomized (high IgE ≥ 0.5 kU/L). Birth during the grass pollen season months and cumulative exposure to outdoor grass pollen counts during pregnancy with cord blood IgE were analysed using multinomial regression and analysed in meta-analysis using binomial regression adjusted for potential confounders. RESULTS: Birth during the grass pollen season had higher pooled odds of cord blood IgE >0.5 kU/L 1.37 (95% CI 1.06, 1.77) in a meta-analysis with little heterogeneity between the three cohorts. Cumulative exposure to outdoor grass pollen counts during the entire pregnancy was associated with slightly lower pooled odds but significant (OR = 0.98, 95% CI: 0.96 to 0.99). CONCLUSIONS: Birth during grass pollen seasons were associated with increased risk of high cord blood IgE in cities from both hemispheres, but high pollen loads in the environment during the entire pregnancy appeared protective. As IgE responses develop during the first months of life, our study findings provide new insights into the mechanisms of grass pollen exposure at birth and shortly after on possible allergic respiratory diseases.

ObjectiveThe purpose of the present systematic review was to synthesize evidence from the literature to assess efficacy of the Mediterranean dietary pattern in childhood asthma.Design/SettingA systematic search of six databases, three clinical trial registries and hand-search of peer-reviewed articles was conducted up to 29 October 2016. Inclusion criteria included exposure to a Mediterranean dietary pattern, measurement of asthma symptoms and study population of children aged ResultsOf the 436 articles identified, after removal of duplicates and based on inclusion criteria, fifteen observational studies conducted in Mediterranean and non-Mediterranean countries were relevant. No randomized controlled trials were retrieved. Twelve studies reported an inverse association between adherence to a Mediterranean dietary pattern and asthma in children, two studies showed no association and one study showed an increase in asthma symptoms. In fourteen out of fifteen studies, quality assessment checks revealed good reliability and validity among study methodologies.ConclusionsThe current systematic review revealed a consistent inverse relationship (protective) between a Mediterranean dietary pattern and asthma in children. Future well-designed randomized controlled trials are needed to provide solid evidence. Nevertheless, the existing level of evidence adds to the public health message relating to the beneficial effects of a Mediterranean-type diet in children suffering with asthma.

Background The numbers of patients with drug resistance TB (DR-TB) increased annually by over 20% globally in the last decade. However, data on the prevalence of DR-TB in Indonesia are limited. The objective of this study to estimate the proportion of DR-TB in new and previously treated TB cases, and to identify comorbidities and risk factors. Methods This study has been conducted at seven hospitals throughout Indonesia since March 2017. Clinically TB patients ≥18-year-old were enrolled and followed until 6 months after treatment completed. Demography and clinical data were recorded; sputum, blood, urine, and PBMC were collected at several time points. AFB smear, sputum culture, Xpert MTB/RIF, and drug sensitivity tests were performed. Drug resistance TB is determined by Xpert MTB/RIF. Results Of 151 enrolled patients, 103 (68%) were confirmed M. tuberculosis by Xpert MTB/RIF, and 47 (46%) were confirmed rifampicin resistance. The distribution of DR-TB in each study site is shown in Figure 1. Among those with comorbidities (38%), comorbidity with diabetes (based on HbA1c level and diabetes history), HIV, and cancer was 9%, 26%, and 7%. Demography, nutrition status, contact and treatment history, and comorbidities are shown in Table 1. DR-TB primary infection contributes to 23% of DR-TB cases. Biomarkers that may predict treatment failure and TB-genotyping are underway. Conclusion The proportion of DR-TB in both new and previously treated patients in our cohort was significantly higher than the estimated number from the WHO and Ministry of Health. TB is a serious threat for public health and mitigation plan must be implemented at all levels. Disclosures All authors: No reported disclosures.

Secondary dengue infection by heterotypic serotypes is associated with severe manifestations of disease, that is, dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). The World Health Organization (WHO) has recommended criteria based on the hemagglutination inhibition (HI) test to distinguish between primary and secondary dengue infections. Since the HI test has practical limitations and disadvantages, we evaluated the accuracy of WHO HI criteria and compared it with criteria based on an IgG enzyme-linked immunosorbent assay (ELISA) using a plaque reduction neutralization test (PRNT) as the gold standard. Both WHO HI criteria and IgG ELISA criteria performed strongly (16/16) in determining primary infection. However, to determine secondary infection, the IgG ELISA criteria performed better (72/73) compared to the WHO HI criteria (23/73).

Background Dengue has emerged as one of the most important infectious diseases in the last five decades. Evidence indicates the expansion of dengue virus endemic areas and consequently the exponential increase of dengue virus infections across the subtropics. The clinical manifestations of dengue virus infection include sudden fever, rash, headache, myalgia and in more serious cases, spontaneous bleeding. These manifestations occur in children as well as in adults. Defining the epidemiology of dengue in a given area is critical to understanding the disease and devising effective public health strategies. Methodology/Principal Findings Here, we report the results from a prospective cohort study of 4380 adults in West Java, Indonesia, from 2000–2004 and 2006–2009. A total of 2167 febrile episodes were documented and dengue virus infections were confirmed by RT-PCR or serology in 268 cases (12.4%). The proportion ranged from 7.6 to 41.8% each year. The overall incidence rate of symptomatic dengue virus infections was 17.3 cases/1,000 person years and between September 2006 and April 2008 asymptomatic infections were 2.6 times more frequent than symptomatic infections. According to the 1997 WHO classification guidelines, there were 210 dengue fever cases, 53 dengue hemorrhagic fever cases (including one dengue shock syndrome case) and five unclassified cases. Evidence for sequential dengue virus infections was seen in six subjects. All four dengue virus serotypes circulated most years. Inapparent dengue virus infections were predominantly associated with DENV-4 infections. Conclusions/Significance Dengue virus was responsible for a significant percentage of febrile illnesses in an adult population in West Java, Indonesia, and this percentage varied from year to year. The observed incidence rate during the study period was 43 times higher than the reported national or provincial rates during the same time period. A wide range of clinical severity was observed with most infections resulting in asymptomatic disease. The circulation of all four serotypes of dengue virus was observed in most years of the study., Author Summary Dengue is the fastest spreading mosquito borne diseases in the world and is endemic in most tropical and sub-tropical countries with an estimated 96 million infections resulting in clinical disease annually. Population-based longitudinal prospective studies are essential for understanding dengue virus in the natural setting and developing prevention strategies to curtail the impact of disease. We present the results of a longitudinal cohort study of adults in West Java, Indonesia that was conducted between 2000–2004 and 2006–2009. We found that in adults, dengue virus was a significant cause of febrile illness. The entire spectrum of clinical severity was observed with most dengue virus infections manifesting as asymptomatic. The incidence of symptomatic dengue virus infections observed in this cohort was much higher than reported national or provincial rates. In addition, we observed all four dengue virus serotypes circulating during most years of the study.

Background : The decline of age at menarche has been reported in several countries, it occurred because of genetic, ethnic, and socioeconomic improvement in nutritional status and environment. The improvement of nutritional status has occurred globally all over the world including in Indonesia. One of the measuring tools in nutritional status is body mass index (BMI). The objective of the study was to assess the correlation between BMI and age at menarche. Methods : A cross-sectional study was carried out among girls aged 9–15 years old in Jatinangor, from May–November 2013. The sample of this study was chosen with cluster random sampling. Age at menarche information was collected through a questionnaire. Body mass index was calculated from measurement of body weight and height. Data was analyzed using Spearman correlation test. Results : Out of three hundred and sixty nine subjects participating in this study, sixty seven were included in the inclusive criteria. According to the classification of BMI of underweight, normal, overweight, and obese, there were 1, 55, 8, and 3 persons, respectively. Mean of BMI was 19.04 and mean age at menarche was 12.72 years, which showed a non significant result (r=-0.013; p= 0.458). Conclusions : Age at menarche was not correlated with BMI. [AMJ.2015;2(4):521–4] DOI: 10.15850/amj.v2n4.656

BackgroundIn March 2012, the Xpert MTB/RIF assay (Xpert) was introduced in three provincial public hospitals in Indonesia as a novel diagnostic to detect tuberculosis and rifampicin resistance among high risk individuals.ObjectiveThis study assessed the effects of using Xpert in place of conventional solid and liquid culture and drug-susceptibility testing on case detection rates, treatment initiation rates, and health system delays among drug-resistant tuberculosis (TB) patients.MethodsCohort data on registration, test results and treatment initiation were collected from routine presumptive patient registers one year before and one year after Xpert was introduced. Proportions of case detection and treatment initiation were compared using the Pearson Chi square test and median time delays using the Mood's Median test.ResultsA total of 975 individuals at risk of drug-resistant TB were registered in the pre-intervention year and 1,442 in the post-intervention year. After Xpert introduction, TB positivity rate increased by 15%, while rifampicin resistance rate reduced by 23% among TB positive cases and by 9% among all tested. Second-line TB treatment initiation rate among rifampicin resistant patients increased by 19%. Time from client registration to diagnosis was reduced by 74 days to a median of a single day (IQR 0-4) and time from diagnosis to treatment start was reduced by 27 days to a median of 15 days (IQR 7-51). All findings were significant with pConclusionCompared to solid and liquid culture and drug-susceptibility testing, Xpert detected more TB and less rifampicin resistance, increased second-line treatment initiation rates and shortened time to diagnosis and treatment. This test holds promise to improve rapid case finding and management of drug-resistant TB patients in Indonesia.

M. Rachmawati 1,∗, B.S. Hernowo2, A.M. Maskoen3, S. Masria 4 1Medical Faculty of Bandung Islamic University, Indonesia 2 Department of Pathology Anatomy, Hasan Sadikin Hospital, Faculty of Medicine Universitas Padjadjaran, Indonesia 3 Department of Biochemistry, Faculty of Medicine Universitas Padjadjaran, Indonesia 4 Department of Microbiology, Faculty of Medicine Universitas Padjadjaran, Indonesia