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Tuberculosis preventive therapy (TPT) for people living with HIV (PLHIV) has been recommended by Indonesia’s National TB Program since 2014 but has seen limited implementation. This study describes TB screening and TPT initiation from 2019 to 2022 among eight healthcare facilities supported by the Zero TB Yogyakarta (ZTB) project. ZTB assigned a dedicated nurse to assist with active TB screening among PLHIV and recommended the immediate initiation of TPT as an innovation implemented. Data were obtained from the national HIV program reporting system, routinely reported by ART clinics from 2019 to 2022. We conducted a descriptive analysis, comparing the pre-intervention and intervention periods. During the intervention, there was a significant increase in PLHIV visits to healthcare facilities where TPT eligibility was assessed. At health centers, TB screening coverage for PLHIV decreased toward the end of the baseline period but recovered during the intervention. The number of PLHIV starting TPT also rose during the intervention. While the direct impact of ZTB is difficult to measure, the changes observed indicate progress in integrating TB/HIV services and enhancing TB prevention among PLHIV. Ongoing support, training, and supervision of healthcare facilities are crucial for improving TB screening and TPT provision.

Pneumonia is a lower tract respiratory infection due to bacteria or viruses. It is a severe disease in the pediatric population. Pneumonia is the leading cause of mortality in children under five years worldwide. One of the problems with pneumonia is the diagnosis, as the symptoms of pneumonia may overlap with other diseases, such as asthma and bronchiolitis. In this work, we propose to develop a method for classifying pneumonia and non-pneumonia using X-ray images. We collected 60 X-ray images from Dr. Sardjito Hospital, Yogyakarta, Indonesia, and the dataset from Kaggle. We processed these images through pre-processing algorithms to enhance the image quality, segmentation, white pixel computation, and classification. The novelty of our method is using the ratio of the white pixels from edge detection using the Canny algorithm with the white pixels from segmentation for classifying pneumonia/non-pneumonia. In the Kaggle dataset, our proposed method achieved an accuracy of 86.7%, a sensitivity of 100%, and a specificity of 85%. The classification using the dataset from Dr. Sardjito Hospital yields sensitivity, specificity, and accuracy of 80%, 60%, and 66.7%, respectively. Despite the low performance in the results, we proved our novel feature, ratio of white pixels, can be used to classify pneumonia/non-pneumonia. We also identified that the local dataset is essential in the algorithm development as it has a different quality from the dataset from modern countries. Further, our simple method can be developed further to support pneumonia diagnosis in resource-limited settings where the advanced computing devices or cloud connection are not available.

IntroductionThe impact of climate change on ambient temperatures threatens to worsen pediatric pneumonia-related outcomes considerably. This study examined the associations of temperature variation and extreme temperature with pediatric pneumonia-related events using a meta-analysis.MethodsWe systematically searched PubMed, Medline, Embase, and Web of Science databases for relevant literature, and the quality of evidence was assessed. Fixed and random-effects meta-analyses were performed to calculate the pooled relative risks (RRs) of the associations with pneumonia-related events.ResultsWe observed that a 1°C temperature variation increased the RR of pneumonia events by 1.06-fold (95% confidence interval (CI): 1.03–1.10). A 1°C temperature variation increased the RR by 1.10-fold of the pediatric pneumonia hospital admissions (95% CI: 1.00–1.21) and 1.06-fold of the pediatric pneumonia emergency department visits (95% CI: 1.01-1.10). Extreme cold increased the RR by 1.25-fold of the pediatric pneumonia events (95% CI: 1.07–1.45). A 1°C temperature variation increased the RR of pneumonia events in children by 1.19-fold (95% CI: 1.08–1.32), girls by 1.03-fold (95% CI: 1.02–1.05), and in temperate climate zones by 1.07-fold (95% CI: 1.03–1.11). Moreover, an increase in extreme cold increased the RR of pneumonia events in children by 2.43-fold (95% CI: 1.72–3.43), girls by 1.96-fold (95% CI: 1.29–2.98) and in temperate climate zones by 2.76-fold (95% CI: 1.71–4.47).ConclusionOur study demonstrated that pediatric pneumonia events are more prevalent among children, particularly girls, and individuals residing in temperate climate zones. Climate change represents an emergent public health threat, affecting pediatric pneumonia treatment and prevention..Systematic Review RegistrationPROSPERO (CRD42022378610).

Active-case finding (ACF) using chest X-ray is an essential method of finding and diagnosing Tuberculosis (TB) cases that may be missed in Indonesia’s routine TB case finding. This study compares active and passive TB case-finding strategies. A retrospective study of TB case notification was conducted. Data between 1 January and 31 December 2021, was used. The population in this study were TB cases notified from Kulon Progo District health facilities, including those found through routine activities or active-case findings. A total of 249 TB cases were diagnosed in Kulon Progo in 2021, and 102 (41%) were bacteriologically confirmed. The TB patients’ ages ranged from 0 to 85 years (median 52, IQR 31–61). The majority of cases were male (59%, 147/249) and mostly among people aged 15–59 (61.4%, 153/249). The proportion of clinical TB diagnoses among cases found from active-case findings was 74.7% (68/91) while the proportion among passive-case findings was 50% (79/158). Active-case finding contributed 91 (36.5%) TB cases to the total cases detected in Kulon Progo in 2021. The use of chest X-rays in active-case findings likely contributed to the detection of a higher proportion of clinical TB than in passive-case findings.

Background Learning environment in a pediatric specialist training program is complex and may influence trainees’ performance and achievement. We evaluated the trainees’ perception on learning environment and compared it between levels of the training. Methods We conducted a cross-sectional study to pediatric trainees in Pediatric Specialist Training Program at Universitas Gadjah Mada, Yogyakarta, Indonesia in May 2019. The data was collected online using the Postgraduate Hospital Educational Environment Measure (PHEEM) questionnaire, which was translated into Indonesian language and was self-completed by the trainees. Results All (136) trainees, which consisted of 35 (25.7%) junior, 44 (32.3%) middle, and 57 (42%) senior levels, completed the survey. The mean total score of PHEEM for all trainees was 108.10 (+ 17.03), which was not different between levels of the trainees. The mean scores for the role of autonomy, teaching, and social support were not different between levels of training either. Nevertheless, the junior scored less than the middle and senior trainees for questions on performing inappropriate tasks. Conclusion The learning environment of the pediatric training program in our setting was perceived good but improvement was required. There was no difference in perception of learning environment based on the level of the training.

Background Respiratory infection is a common morbidity and a major cause of mortality in immunocompromised children. Hence, identification of clinical parameters that predict mortality among immunocompromised children with respiratory infections is of importance to provide timely and appropriate intervention. Objective To determine predictors of mortality in immunocompromised children with respiratory infections. Methods We conducted a prospective cohort study of immunocompromised children aged 18 years or younger with respiratory tract infections who were admitted to Dr. Sardjito Hospital, Yogyakarta, Indonesia. All eligible children were prospectively followed up until hospital discharge. Clinical and laboratory parameters during the first 24 hours of hospitalization were collected. Results Of 79 eligible children, the overall mortality was 11 subjects (13.9%). Fever, tachycardia, tachypnea, cyanosis, leukopenia, neutropenia, thrombocytopenia, and pleural effusion were predictive factors of mortality in bivariate analysis (P

In Indonesia, the implementation of tuberculosis (TB) contact investigation is limited, with low detection rates. We report the yield of and risk factors for TB disease and infection for household contacts (HHCs) investigated using chest X-ray (CXR) screening. We identified HHCs aged five years and above of bacteriologically confirmed index cases from 2018 to 2022 in Yogyakarta City and Kulon Progo. All HHCs were offered screening for TB symptoms; TB infection testing with either tuberculin skin testing or interferon gamma release assay; and referral for CXR. Sputum from those with symptoms or CXR suggestive of TB was tested with Xpert MTB/RIF. Risk factors for active TB disease and latent TB infection (LTBI) were identified by logistic regression models. We screened 2857 HHCs for TB between June 2020 and December 2022, with 68 (2.4%) diagnosed with active TB. Of 2621 HHCs eligible for LTBI investigation, 1083 (45.7%) were diagnosed with LTBI. The factors associated with active TB were age, being underweight, diabetes mellitus, urban living, and sleeping in the same house as an index case. Factors associated with LTBI were increasing age and male gender. Conclusions: Screening for HHC including CXR and TST/IGRA yielded a moderate prevalence of TB disease and infection.

Coverage of tuberculosis preventive treatment (TPT) in Indonesia is inadequate, and persons who start TPT often do not complete treatment. In 2020, Zero TB Yogyakarta implemented person-centered contact investigation and shorter TPT regimen provision in collaboration with primary health care centers. Between 1 January 2020 and 31 August 2022, we assessed eligibility for TPT among household contacts of persons with bacteriologically confirmed TB (index cases) and offered them a 3-month TPT regimen (3RH or 3HP). A dedicated nurse monitored contacts on TPT for treatment adherence and side effects every week in the first month and every two weeks in the next months. Contacts were also able to contact a nurse by phone or ask for home visits at any point if they had any concerns. A total of 1016 contacts were eligible for TPT: 772 (78.8%) started short regimen TPT with 706 (91.5%) completing their TPT. Side effects were reported in 26 (39%) of the non-completion group. We conclude that high rates of TPT uptake and completion among contacts assessed as eligible for TPT can be achieved through person-centered care and the use of shorter regimens. Side-effect monitoring and management while on TPT is vital for improving TPT completion.

Background Exhaled carbon monoxide has been related to the degree of inflammation. An easy, inexpensive, and non-invasive test to measure exhaled CO levels (eCO) may help in supporting the diagnosis of asthma and allergic rhinitis (AR) in children. Objective To compare the eCO levels in children with asthma, AR, or both asthma and AR, to children without asthma or AR. Methods This was a cross-sectional study involving 450 children aged 13-14 years in Yogyakarta. Asthma and AR were determined according to the International Study of Asthma and Allergies in Childhood (ISAAC) study criteria, while eCO level was examined using a Smokerlyzer®. The levels of eCO between groups were analyzed using Kruskal-Wallis and Mann-Whitney tests. Results Of 450 children, 48 (10.67%) had asthma only, 91 (20.22%) had AR only, 67 (14.89%) had both asthma and AR, and 244 (54.22%) had neither asthma nor AR. The eCO levels of children with asthma or AR were not significantly different compared to those without asthma and AR (P=0.33 and P=0.19, respectively). However, children with both asthma and AR had significantly higher eCO level compared to children without asthma and AR (P< 0.001). Conclusion The levels of eCO in children with asthma only or AR only are similar to those without both diseases. Children with both asthma and AR have significant higher eCO compared to healthy children.

BackgroundDiscrimination of bacterial and viral etiologies of childhood community-acquired pneumonia (CAP) is often challenging. Unnecessary antibiotic administration exposes patients to undue risks and may engender antimicrobial resistance. This study aimed to develop a prediction model using epidemiological, clinical and laboratory data to differentiate between bacterial and viral CAP.MethodsData from 155 children with confirmed bacterial or mixed bacterial and viral infection (N = 124) and viral infection (N = 31) were derived from a comprehensive assessment of causative pathogens [Partnerships for Enhanced Engagement in Research-Pneumonia in Pediatrics (PEER-PePPeS)] conducted in Indonesia. Epidemiologic, clinical and biomarker profiles (hematology and inflammatory markers) were compared between groups. The area under the receiver operating characteristic curve (AUROC) for varying biomarker levels was used to characterize performance and determine cut-off values for discrimination of bacterial and mixed CAP versus viral CAP. Diagnostic predictors of bacterial and mixed CAP were assessed by multivariate logistic regression.ResultsDiarrhea was more frequently reported in bacterial and mixed CAP, while viral infections more frequently occurred during Indonesia’s rainy season. White blood cell counts (WBC), absolute neutrophil counts (ANC), neutrophil-lymphocyte ratio (NLR), C-reactive protein (CRP), and procalcitonin (PCT) were significantly higher in bacterial and mixed cases. After adjusting for covariates, the following were the most important predictors of bacterial or mixed CAP: rainy season (aOR 0.26; 95% CI 0.08–0.90; p = 0.033), CRP ≥5.70 mg/L (aOR 4.71; 95% CI 1.18–18.74; p = 0.028), and presence of fever (aOR 5.26; 95% CI 1.07–25.91; p = 0.041). The model assessed had a low R-squared (Nagelkerke R2 = 0.490) but good calibration (p = 0.610 for Hosmer Lemeshow test). The combination of CRP and fever had moderate predictive value with sensitivity and specificity of 62.28 and 65.52%, respectively.ConclusionCombining clinical and laboratory profiles is potentially valuable for discriminating bacterial and mixed from viral pediatric CAP and may guide antibiotic use. Further studies with a larger sample size should be performed to validate this model.

Healthcare workers (HCWs) are at risk of contracting TB, particularly when in high tuberculosis (TB) burden settings. Routine surveillance data and evidence are limited on the burden of TB amongst HCWs in Indonesia. We aimed to measure the prevalence of TB infection (TBI) and disease among HCWs in four healthcare facilities in Yogyakarta province in Indonesia, and explore risk factors for TBI. A cross-sectional TB screening study targeted all HCWs from four pre-selected facilities (1 hospital, 3 primary care) in Yogyakarta, Indonesia. Voluntary screening included symptom assessment, Chest X-ray (CXR), Xpert MTB/RIF (if indicated) and tuberculin skin test (TST). Analyses were descriptive and included multivariable logistic regression. Of 792 HCWs, 681 consented (86%) to the screening; 59% (n = 401) were female, 62% were medical staff (n = 421), 77% worked in the one participating hospital (n = 524), and the median time working in the health sector was 13 years (IQR: 6-25 years). Nearly half had provided services for people with TB (46%, n = 316) and 9% reported ever having TB (n = 60). Among participants with presumptive TB (15%, n = 99/662), none were diagnosed microbiologically or clinically with active TB disease. TBI was detected in 25% (95% CI: 22-30; n = 112/441) of eligible HCWs with a TST result. A significant association was found between TB infection and being male (adjusted Odds Ratio (aOR) 2.02 (95%CI: 1.29-3.17)), currently working in the participating hospital compared to primary care (aOR 3.15 (95%CI: 1.75-5.66)), and older age (1.05 OR increase per year of life between 19-73 years (95%CI: 1.02-1.06)). This study supports prioritisation of HCWs as a high-risk group for TB infection and disease, and the need for comprehensive prevention and control programs in Indonesia. Further, it identifies characteristics of HCWs in Yogyakarta at higher risk of TBI, who could be prioritised in screening programs if universal coverage of prevention and control measures cannot be achieved.

The World Health Organization recommends using chest X-ray (CXR) in active case finding (ACF) to improve case detection. This study aimed to describe the spectrum and outcomes of TB disease diagnosed through a mobile community based ACF program in Yogyakarta. This prospective cohort study included people attending a TB ACF program in Yogyakarta between 1 January 2021 to 30 June 2022. Participants ≥10 years old underwent CXR, symptom screening, and Xpert MTB/RIF testing of sputum. Subclinical TB was defined as asymptomatic active TB, whether bacteriologically confirmed or not. Treatment outcome data were obtained from the national program TB database. 47,735 people attended the ACF program; the yield of TB disease was 0.86% (393/45,938). There were 217 symptomatic cases, of whom 72 (33.2%) were bacteriologically confirmed, and 176 asymptomatic cases, with 52 (29.5%) bacteriologically confirmed. Treatment success was 70.7% with high loss to follow up (9%) and not evaluated (17.1%). Multivariate analysis demonstrated weak evidence for lower unsuccessful outcomes in symptomatic versus subclinical TB (aOR 0.6, 95% CI 0.36–0.998). TB ACF programs utilizing CXR may diagnose a high proportion of subclinical TB. Linkage to care in ACF program is important to increase successful treatment outcomes.

Background: The intense workload and complex learning environment in pediatric specialist training program may lead to trainees’ burnout. The study aimed to assess burnout and the associated factors among pediatric trainees in Indonesia. Methods: We conducted a multicentre study involving all (15) pediatric training institutions in Indonesia from June to August 2019. A General Oldenburg Burnout Inventory (OLBI) was translated to Indonesian language. The OLBI comprised of 16 questions which assessed exhaustion (8 questions) and disengagement (8 questions). The online questionnaire was self-completed by pediatric trainees in the study sites. Ordinal regressions were performed to assess risk factors (age, marital, sex, resident stage of training, and university) for exhaustion and disengagement. Results: A total of 841 trainees from 15 pediatric training institutions in Indonesia completed the survey (response rate 71.2%). The majority (72.1%) of the trainees was female with mean age of 31.2 ± 2.9 years. The Cronbach’s-alpha was 0.74. The mean exhaustion and disengagement scores were 2.58±0.23 and 2.51±0.23, respectively. The proportion of vigor, mild, moderate and severe exhaustion were 48.3%; 42.0%; 9.0%; and 0.7%, respectively. The proportion of dedicated, mild, moderate and severe disengagement were 36.9%; 46.5%; 14.5%; and 2.1%, respectively. The stage of training (junior-intermediate stage), after adjusted to age, sex and institution was significantly increase the risk for exhaustion [odd ratio 1.47 (95%CI; 1.22-1.76)]. Disengagement level was significantly different among pediatric training institutions (located in Java and outer Java) [odd ratio 0.68 (95%CI; 0.529-0.885)]. Conclusion: Burnout was common among pediatric trainees in Indonesia.

Abstract Background Transmission within families and multiple spike protein mutations have been associated with the rapid transmission of SARS-CoV-2. We aimed to: (1) describe full genome characterization of SARS-CoV-2 and correlate the sequences with epidemiological data within family clusters, and (2) conduct phylogenetic analysis of all samples from Yogyakarta and Central Java, Indonesia and other countries. Methods The study involved 17 patients with COVID-19, including two family clusters. We determined the full-genome sequences of SARS-CoV-2 using the Illumina MiSeq next-generation sequencer. Phylogenetic analysis was performed using a dataset of 142 full-genomes of SARS-CoV-2 from different regions. Results Ninety-four SNPs were detected throughout the open reading frame (ORF) of SARS-CoV-2 samples with 58% (54/94) of the nucleic acid changes resulting in amino acid mutations. About 94% (16/17) of the virus samples showed D614G on spike protein and 56% of these (9/16) showed other various amino acid mutations on this protein, including L5F, V83L, V213A, W258R, Q677H, and N811I. The virus samples from family cluster-1 (n = 3) belong to the same clade GH, in which two were collected from deceased patients, and the other from the survived patient. All samples from this family cluster revealed a combination of spike protein mutations of D614G and V213A. Virus samples from family cluster-2 (n = 3) also belonged to the clade GH and showed other spike protein mutations of L5F alongside the D614G mutation. Conclusions Our study is the first comprehensive report associating the full-genome sequences of SARS-CoV-2 with the epidemiological data within family clusters. Phylogenetic analysis revealed that the three viruses from family cluster-1 formed a monophyletic group, whereas viruses from family cluster-2 formed a polyphyletic group indicating there is the possibility of different sources of infection. This study highlights how the same spike protein mutations among members of the same family might show different disease outcomes.

Objectives The WHO currently recommends stool testing using GeneXpert MTB/Rif (Xpert) for the diagnosis of paediatric tuberculosis (TB). The simple one-step (SOS) stool method enables processing for Xpert testing at the primary healthcare (PHC) level. We modelled the impact and cost-effectiveness of implementing the SOS stool method at PHC for the diagnosis of paediatric TB in Ethiopia and Indonesia, compared with the standard of care.Setting All children (age

Objective To identify aetiologies of childhood community-acquired pneumonia (CAP) based on a comprehensive diagnostic approach.Design ‘Partnerships for Enhanced Engagement in Research-Pneumonia in Paediatrics (PEER-PePPeS)’ study was an observational prospective cohort study conducted from July 2017 to September 2019.Setting Government referral teaching hospitals and satellite sites in three cities in Indonesia: Semarang, Yogyakarta and Tangerang.Participants Hospitalised children aged 2–59 months who met the criteria for pneumonia were eligible. Children were excluded if they had been hospitalised for >24 hours; had malignancy or history of malignancy; a history of long-term (>2 months) steroid therapy, or conditions that might interfere with compliance with study procedures.Main outcome(s) measure(s) Causative bacterial, viral or mixed pathogen(s) for pneumonia were determined using microbiological, molecular and serological tests from routinely collected specimens (blood, sputum and nasopharyngeal swabs). We applied a previously published algorithm (PEER-PePPeS rules) to determine the causative pathogen(s).Results 188 subjects were enrolled. Based on our algorithm, 48 (25.5%) had a bacterial infection, 31 (16.5%) had a viral infection, 76 (40.4%) had mixed bacterial and viral infections, and 33 (17.6%) were unable to be classified. The five most common causative pathogens identified were Haemophilus influenzae non-type B (N=73, 38.8%), respiratory syncytial virus (RSV) (N=51, 27.1%), Klebsiella pneumoniae (N=43, 22.9%), Streptococcus pneumoniae (N=29, 15.4%) and Influenza virus (N=25, 13.3%). RSV and influenza virus diagnoses were highly associated with Indonesia’s rainy season (November–March). The PCR assays on induced sputum (IS) specimens captured most of the pathogens identified in this study.Conclusions Our study found that H. influenzae non-type B and RSV were the most frequently identified pathogens causing hospitalised CAP among Indonesian children aged 2–59 months old. Our study also highlights the importance of PCR for diagnosis and by extension, appropriate use of antimicrobials.Trail registration number NCT03366454

Background The PELOD-2 score, which has been widely used to predict multiple organ dysfunction, may be used to predict mortality. Nevertheless, blood gas analyses (BGA) and lactate measurements required for the PELOD-2 cannot be performed in most limited resource settings. Objective To evaluate the performance of modified PELOD-2, without BGA and lactate, to predict mortality in critically ill children. Methods This retrospective cohort study in critically ill children admitted to the pediatric intensive care unit (PICU), Dr. Sardjito Hospital, Yogyakarta, was undertaken from January to December 2018. The modifications to the PELOD-2 score were PELOD-2A (without BGA), PELOD-2B (without lactate), and PELOD-2C (without BGA and lactate). The modified PELOD-2 scores were evaluated using receiver operating characteristic (ROC) curve for discrimination, and Hosmer-Lemeshow goodness-of-fit test for calibration. Results Of 130 subjects, 68 (52.3%) died. A PELOD-2 score cut-off of 6.5 and modified PELOD-2A, 2B, and 2C had sensitivities for predicting mortality of 73.5%, 67.7%, 70.6%, and 63.2%, respectively, and specificities of 75.8%, 77.4%, 77.4%, and 79%, respectively. The area under curve (AUC) of the PELOD-2 score was 78.3 (95%CI 70.5 to 86.2). The AUCs of the modified PELOD-2 scores ranged from 76.8 (95%CI 68.7 to 84.9) to 77.9 (95% CI 69.9 to 85.8). The positive predictive values of PELOD-2 and modified PELOD-2A, 2B, 2C were 76.9%, 76.7%, 77.4% and 76.8%, respectively. The Hosmer-Lemeshow goodness-of-fit test showed good calibration for PELOD-2 (x2=8.74; P=0.27) and modified PELOD-2A (x2=4.91; P=0.67). Conclusion The PELOD-2A, modified without BGA, can still predict mortality well in critically ill PICU patients when using a cut-off score ≥ 6.5.

Abstract In Indonesia, pneumococcal disease represents a considerable public health concern; however, published data on the epidemiology, nasopharyngeal carriage, serotype prevalence, and antibiotic resistance of Streptococcus pneumoniae in this region are limited. Therefore, this article reviews the available data from a variety of sources and also summarizes pneumococcal conjugate vaccine implementation and recommendations in Indonesia and subsequent impact on pneumococcal disease. Regional pneumococcal vaccination recommendations in Asia were also reviewed. Studies showed that pneumococcal nasopharyngeal carriage prevalence in Indonesia was approximately 43% to 55% in healthy children aged less than 5 years, which varied by age group, region, and year. Serotype analysis of pneumococcal nasopharyngeal carriage isolates in Indonesia revealed that 38% to 60% of isolates would be covered by the 13-valent pneumococcal conjugate vaccine (PCV13). The antimicrobial resistance of pneumococcal disease has increased over time; between 1997 and 2012, resistance to penicillin and sulfamethoxazole increased from 0% to 28% and 9% to 62%, respectively. Inclusion of pneumococcal conjugate vaccines into immunization programs is being implemented gradually. In 2017, Indonesia implemented a regional PCV13 immunization program in Lombok with a 2 + 1 vaccination schedule that was expanded in 2018–2019 to West Nusa Tenggara and Bangka Belitung Provinces; this expansion is predicted to substantially reduce the burden of pneumococcal disease in Indonesia. Overall, the limited data available regarding pneumococcal disease in Indonesia highlight the unmet need for comprehensive disease surveillance studies in this region that can help direct vaccination strategies.

Background The Xpert MTB/RIF assay demonstrated a better diagnostic value than sputum smear for TB in adults and children. Objective To evaluate the use of Xpert MTB/RIF for TB diagnosis in children. Methods We conducted a prospective study in Yogyakarta, Indonesia, involving 19 primary health centers (PHCs) and one provincial hospital. Children aged 0-14 years with suspected TB who visited the study sites were screened. Subjects underwent history-taking, physical examination, tuberculin skin test, chest X-ray, as well as sputum induction for Xpert MTB/RIF assay, sputum smear, and TB culture. The diagnosis of TB was made by doctors based on the results of investigations, as follows: certain TB (bacteriological confirmation), probable TB, and possible TB. Results Of 80 subjects, 21 (26%) were diagnosed with TB disease (4 certain TB and 17 probable TB). Sputum induction was successfully performed in 79 children. None of the children had positive sputum smears. Mycobacterium tuberculosis was detected by Xpert MTB/RIF in 4 children, accounting for 5% of all children with suspected TB, or 19% among children with TB disease. The 4 Xpert MTB/RIF-positive subjects had severe TB disease and were rifampicin-sensitive. Conclusion Xpert MTB/RIF may improve case finding among children with severe TB disease with negative sputum smear.

Latar belakang. Stunted pada usia sekolah menyebabkan kemampuan kognitif rendah, fungsi fisik tidak optimal, dan produktivitas masa depan yang rendah. Tujuan. Mengidentifikasi apakah berat badan lahir rendah (BBLR) merupakan faktor risiko stunted pada anak usia sekolah. Metode. Kami melakukan penelitian kasus-kontrol dari bulan Mei – Desember 2016 yang melibatkan siswa sekolah dasar berusia 6-7 tahun yang dipilih secara cluster random sampling di lima kabupaten di Daerah Istimewa Yogyakarta. Stunted didefinisikan sebagai nilai Z score untuk tinggi badan menurut usia

BACKGROUND: The diagnosis of tuberculosis (TB) in children is challenging by the absence of a practical gold standard. Interferon (IFN)-ginducible protein 10 (IP-10) is a chemokine that may serve as the leading candidate marker in child TB diagnosis. The aim of this study is to assess the diagnostic value of IP-10 in the diagnosis of TB in children. METHODS: We recruited eligible symptomatic and asymptomatic children aged

Young children are most vulnerable to develop severe forms of tuberculosis (TB) and are over-represented among TB deaths. Almost all children estimated to have died from TB were never diagnosed or offered TB treatment.Improved access to TB preventive treatment (TPT) requires major upscaling of household contact investigation with allocation of adequate resources. Symptom-based screening is often discouraged in adults for fear of generating drug resistance, if TB cases are missed. However, the situation in vulnerable young children is different, as they present minimal risk of drug resistance generation. Further, the perceived need for additional diagnostic evaluation presents a major barrier to TPT access and underlies general reluctance to consider pragmatic decentralised models of care.Widespread roll-out of Xpert MTB/RIF Ultra® represents an opportunity for improved case detection in young children, but attaining full impact will require the use of non-sputum specimens. The new Fujifilm SILVAMP TB LAM® urine assay demonstrated good diagnostic accuracy in HIV-positive and malnourished children, but further validation is required. Given the limited accuracy of all available tests and the excellent tolerance of TB drugs in children, the global community may have to accept some over-treatment if we want to close the persistent case detection gap in young children.

Background Children with sepsis often experience hemodynamic failure and would benefit from fluid resuscitation. On the other hand, critically ill children with sepsis have a higher risk of fluid accumulation due to increased capillary hydrostatic pressure and permeability. Therefore, fluid overload may result in higher morbidity and mortality during pediatric intensive care unit (PICU) hospitalization. Objective To evaluate the correlation between fluid overload and the length of mechanical ventilation in children with sepsis admitted to the PICU. Methods Our retrospective cohort study included children aged 1 month-18 years with sepsis who were admitted to the PICU between January 2013 and June 2018 and mechanically-ventilated. Secondary data was extracted from subjects’ medical records. Data analyses used were independent T-test and survival analysis. Results Of 444 children admitted to the PICU, 166 initially met the inclusion criteria. Of those, 17 children were excluded due to congenital heart disease. Subjects’ median age was 19 months and median PELOD-2 score was 8. Eighteen children (12.1%) had positive fluid balance in the first 48 hours. Median mechanical ventilation duration was 5 days. Fluid overload was significantly correlated with length of mechanical ventilation (P=0.01) and PICU mortality (RR=2.06; 95%CI 2.56 to 166; P=0.001). Neither length of PICU stay nor extubation failure were significantly correlated to fluid overload. Conclusion Fluid overload was significantly correlated with length of mechanical ventilation and may be a predictor of mortality in children with sepsis in the PICU.

Background Insulin-like growth factor-1 (IGF-1) deficiency is the major cause of growth disorders and delayed puberty in children with thalassemia. Hence, identifying factors contributing to IGF-1 deficiency in thalassemia is of importance. Objectives To evaluate the correlation between IGF-1 level and nutritional status, ferritin level, pre-transfusion hemoglobin, thyroid, as well as alanine transaminase level. Methods We conducted a study in children aged 2 to 18 years with thalassemia major who visited outpatient clinics at two hospitals in Indonesia, Dr. Sardjito Hospital, Yogyakarta and Dr. Moewardi Hospital, Surakarta, Central Java, from July to December 2015. Clinical, laboratory, and demographic data were reviewed from medical records. IGF-1 levels were measured using an immunochemiluminiscent method. Results A total of 48 children were recruited into the study. Subjects mean IGF-1 level was 109.28 ng/mL (SD 90.26) ng/mL. Seventy-five percent of the children had IGF-1 level < -2SD. Subjects mean ferritin, pre-transfusion hemoglobin and ALT levels were 3.568 (SD 2131.31) ng/mL; 7.97 (SD 0.85) g/dL and 49.7 (SD 43.1), respectively. Most of the children (91.7%) was eutyroid, with a mean of TSH and FT4 level was 2.7 (SD 1.5) nmol/L and 12.3 (SD 7.1) μIU/ml, respectively. Ferritin level had no significant correlation with IGF-1 level (r=-0.794; P=0.431). However, a strong, positive correlation was documented between pre-transfusion hemoglobin level and IGF-1 level (r=2.380; P=0.022). Multivariate linear regression analysis revealed that factors with significant correlations to IGF-1 level were pre-transfusion hemoglobin level

Abstract Background People in close contact with tuberculosis should have screening and appropriate management, as an opportunity for active case detection and prevention. However, implementation of tuberculosis contact screening and management is limited in high-burden settings. Behaviour change is needed across three levels of the healthcare system—policymakers, healthcare providers, and patients. To bridge the wide policy-practice gap, this study draws on the Consolidated Framework for Implementation Research, the Behaviour Change Wheel, and the RE-AIM model (Reach, Effectiveness, Adoption, Implementation, Maintenance) to respectively understand barriers, implement change, and evaluate process and outcome. Methods This methods paper describes a mixed-methods intervention study in Eastern Indonesia. Quantitative data will be collected during baseline, intervention, and sustainability periods and analyzed using time series analysis. The primary outcome is the number of individuals completing tuberculosis preventive therapy by the end of the two-year intervention phase. Of an estimated 10,000 contacts during this period, we anticipate that a minimum of 416 will be found to have active TB or will complete preventive therapy. Qualitative data (semi-structured interviews, focus group discussions, and observations) will be collected from consenting healthcare providers, patients, and contacts. Activities to promote policy implementation include healthcare provider training, quarterly continuous quality improvement workshops, a social media discussion forum, and promotional materials. The Consolidated Framework for Implementation Research will be used to identify reasons for limited policy implementation at baseline. The Behaviour Change Wheel will be used to ensure that a suitable range of activities are implemented to facilitate change. The RE-AIM model will be used as the evaluation framework. Discussion Use of theoretical frameworks in combination can ensure a comprehensive understanding of, and robust response to, health policy underimplementation. The selected frameworks are highly applicable to this pragmatic intervention study, in a setting where End TB Strategy targets will not be met without substantial behavior change within health systems. Continuous quality improvement cycles will provide a way to engage staff and stakeholders in understanding local data to motivate behavior change. If successful, up to 500 people could be prevented from developing complications of tuberculosis through early case-finding or receiving preventive therapy over a two-year period. Study registration Australian New Zealand Clinical Trials Register 375803.

Background. Vitamin C, E, D, A, zinc are considered to be essential in preventing and treating of acute respiratory infections (ARI) including COVID-19. Methods. We reviewed published studies evaluating the potential roles of these vitamin and zinc for ARIs and COVID-19 using Medline database, medRxiv, and bibliographic references. Results. Vitamins C, D, and E did not reduce incidence of common cold in general, but vitamin C reduced by half in population with physical and environment stresses. Vitamins C and E shortened duration and reduced severity of common cold. A large-dose vitamin A had no effect on recovery from pneumonia. Zinc improved clinical deterioration and pneumonia duration in under five. The effect on preventing COVID-19 morbidity and related-death was lacking. Conclusions . Although the effects of vitamins and zinc on ARIs including COVID-19 were inconclusive, taking these for a short period during pandemic may be beneficial when there is risks of deficiency.

BackgroundVitamin D deficiency has been associated with acute respiratory infection (ARI) in early life, but this has not been evaluated in Indonesia. We aimed to determine the incidence of ARI in Indonesian infants, and to evaluate the association with vitamin D deficiency.MethodsFrom 23 December 2015 to 31 December 2017, we conducted a community-based prospective cohort study in Yogyakarta province. We enrolled 422 pregnant women and followed their infants from birth until 12 months of age for ARI episodes. Vitamin D status was measured at birth and at age six months. We performed Cox proportional hazard regression analysis to evaluate the association between vitamin D deficiency and pneumonia incidence.ResultsAt study completion, 95% (400/422) of infants retained with a total of 412 child years of observation (CYO). The incidence of all ARI and of WHO-defined pneumonia was 3.89 (95% CI 3.70-4.08) and 0.25 (95% CI 0.21-0.30) episodes per CYO respectively. Vitamin D deficiency at birth was common (90%, 308/344) and associated with more frequent episodes of ARI non-pneumonia (adjusted odds ratio 4.48, 95% CI:1.04-19.34). Vitamin D status at birth or six months was not associated with subsequent pneumonia incidence, but greater maternal sun exposure during pregnancy was associated with a trend to less frequent ARI and pneumonia in infants.ConclusionARI, pneumonia, and vitamin D deficiency at birth were common in Indonesian infants. Minimising vitamin D deficiency at birth such as by supplementation of mothers or safe sun exposure during pregnancy has the potential to reduce ARI incidence in infants in this setting.

ObjectiveTo determine the prevalence of vitamin D deficiency in Indonesian children hospitalized with pneumonia and evaluate the association between vitamin D status and severity of pneumonia.MethodsA hospital-based cross-sectional study was conducted from February 2016 to July 2017 in two district hospitals in Yogyakarta province, Indonesia. Infants and young children aged 2-59 months hospitalized with pneumonia were recruited. Serum blood samples were collected on admission and analyzed for total serum 25-hydroxyvitamin D3 and 25-hydroxyvitamin D2 concentrations using liquid chromatography-tandem mass spectrometry. Vitamin D deficiency was defined as a level of serum vitamin D Results133 children with WHO-defined pneumonia were enrolled in the study and 127 (96%) had their vitamin D status determined. The mean vitamin D concentration was 67 (± 24 SD) nmol/L and 19% of participants were vitamin D deficient. Age younger than 6 months was associated with prolonged hospitalization (> 5 days) and low birth weight and poor nutritional status on admission were risk factors for hypoxemia. However, vitamin D status was not associated with the presence of danger signs, duration of hospitalization, or hypoxemia.ConclusionsOne in every five children hospitalized with pneumonia was vitamin D deficient. Vitamin D status was not associated with the severity of pneumonia.

This research to determine the average cost of illness of inpatient pediatric meningitis patients hospitalized in the hospitals in Yogyakarta. It was a pharmacoeconomic study using the cost of illness method. The calculation of the cost in the care of inpatient pediatric meningitis patients according to a societal perspective was conducted observatively with a cross sectional design. Cost of illness analysis included calculating the costs of direct medical, direct non-medical, and indirect cost. Data were collected from a type-A public hospital and a type-B privatehospital in Yogyakarta by taking medical records, detailed data on meningitis patient care costs, and interviews using questionnaires with caregivers. Analysis of cost of illness calculations applied descriptive analysis methods. In this study, 11 inpatient pediatric meningitis patients were obtained. The average cost of illness for the treatment of inpatient pediatric meningitis patients was IDR 26,224,586±12,814,789, consisting of the average direct medical cost of IDR 23,831,813±12,222,885 (90.88%), the average direct non-medical cost of IDR 1,787,955±832,353 (6.82%), and the average indirect cost of IDR 604,818±337,389 (2.31%). Components of direct medical cost with the largest percentage were drugs and medical supplies (26.46%); while the largest direct non-medical cost were the expenditure of additional needs for the patient's family (72.18%). The indirect cost component came from the reduction of the patient's parents' income while the patient is hospitalized.

The management of childhood tuberculosis (TB) is hampered by the low sensitivity and limited accessibility of microbiological testing. Optimizing clinical approaches is therefore critical to close the persistent gaps in TB case detection and prevention necessary to realize the child mortality targets of the End TB Strategy. In this review, we provide practical guidance summarizing the evidence and guidelines describing the use of symptoms and signs in decision making for children being evaluated for either TB preventive treatment (TPT) or TB disease treatment in high-TB incidence settings. Among at-risk children being evaluated for TPT, a symptom screen may be used to differentiate children who require further investigation for TB disease before receiving TPT. For symptomatic children being investigated for TB disease, an algorithmic approach can inform which children should receive TB treatment, even in the absence of imaging or microbiological confirmation. Though clinical approaches have limitations in accuracy, they are readily available and can provide valuable guidance for decision making in resource-limited settings to increase treatment access. We discuss the trade-offs in using them to make TB treatment decisions.

Pneumonia is the most common cause of morbidity and mortality among young children worldwide. Integrated Management of Childhood Illness (IMCI) is a procedural form in the care of childhood illness which aims to minimize morbidity and mortality rate in children, including pneumonia. This was a cross-sectional study at Samarinda and Kutai Kartanegara community health center from July to October 2015. The health workers’ knowledge was assessed through questionnaire. The quality of IMCI implementation was evaluated through direct observation in primary health care. A total of 46 health workers were involved in this study. Observation of IMCI implementation quality was conducted in 104 children. The majority of respondents (73.9) had sufficient knowledge; however, in terms of direct implementation on the field, most of the respondents (87%) were included in incompetent category. It can be concluded that level of knowledge was related to implementation of cough IMCI in community health center, but the correlation was weak.

Over the past 15 years, and despite many difficulties, significant progress has been made to advance child and adolescent tuberculosis (TB) care. Despite increasing availability of safe and effective treatment and prevention options, TB remains a global health priority as a major cause of child and adolescent morbidity and mortality—over one and a half million children and adolescents develop TB each year. A history of the global public health perspective on child and adolescent TB is followed by 12 narratives detailing challenges and progress in 19 TB endemic low and middle-income countries. Overarching challenges include: under-detection and under-reporting of child and adolescent TB; poor implementation and reporting of contact investigation and TB preventive treatment services; the need for health systems strengthening to deliver effective, decentralized services; and lack of integration between TB programs and child health services. The COVID-19 pandemic has had a significant negative impact on case detection and treatment outcomes. Child and adolescent TB working groups can address country-specific challenges to close the policy–practice gaps by developing and supporting decentral ized models of care, strengthening clinical and laboratory diagnosis, including of multidrug-resistant TB, providing recommended options for treatment of disease and infection, and forging strong collaborations across relevant health sectors.

BackgroundVitamin D deficiency in infants has been associated with an increased risk of a number of diseases but there are limited data on the prevalence and determinants of vitamin D deficiency from tropical settings with high infant morbidity and mortality.ObjectiveTo determine the prevalence and determinants of vitamin D deficiency in infants at birth and at six months of age in Yogyakarta province, Indonesia.DesignSerum vitamin D of eligible infants was measured in cord blood at birth and at six months of age. Factors associated with vitamin D deficiency (serum 25-hydroxyvitamin D ResultsBetween December 2015 to December 2017, 350 maternal-newborn participants were recruited and followed up. Vitamin D deficiency was detected in 90% (308/344) of cord blood samples and 13% (33/255) of venous blood samples at six months. Longer time outdoors (≥2 hours per day) and maternal multivitamin intake containing vitamin D during pregnancy were protective against vitamin D deficiency at birth (AOR: 0.10, 95% CI: 0.01-0.90 and AOR: 0.21, 95% CI: 0.06-0.68, respectively). Risk factors for vitamin D deficiency at six months included lower cumulative skin-sun exposure score (AOR: 1.12, 95% CI: 1.04-1.20), severe vitamin D deficiency at birth (AOR: 7.73, 95% CI: 1.20-49.60) and exclusive breastfeeding (AOR: 2.64, 95% CI: 1.07-6.49) until six months. Among exclusively breast fed (EBF) infants, a higher skin-sun exposure score was associated with reduced vitamin D deficiency risk.ConclusionIn equatorial regions, the role of 'safe' morning sun exposure in infants and mothers in populations with medium to dark brown skin pigmentation and effective interventions to prevent vitamin D deficiency in newborns and EBF infants, need further consideration and evaluation.

Latar belakang. Pneumonia merupakan penyebab utama kematian pada anak usia di bawah lima tahun di negara berkembang. Pengembangan sistem skor yang sederhana untuk memprediksi kematian pada pneumonia dapat meningkatkan kualitas pelayanan dan menurunkan angka kematian anak akibat pneumonia. Tujuan. Menyusun skor prediksi kematian pada anak dengan pneumonia. Metode. Penelitian kohort retrospektif pada anak (umur 2 bulan sampai 5 tahun) yang dirawat di RSUP Dr. Sardjito dengan pneumonia sejak Januari 2009 sampai Desember 2014. Anak dengan rekam medis tidak lengkap atau dengan infeksi HIV dieksklusi. Digunakan metode Spiegelhalter Knill-Jones untuk penyusunan skor kematian. Prediktor kematian dengan likelihood ratio (LHR) ≤0,5 atau ≥2 dimasukkan dalam sistem skor. Cut off point dari skor total ditentukan dengan kurva receiver operating characteristic (ROC). Hasil. Di antara 225 anak yang memenuhi kriteria, 42 (18,7%) meninggal. Prediktor kematian yang memenuhi kriteria LHR adalah usia 6 bulan); frekuensi nadi skor=6 bila takikardia dan -8 bila normal); saturasi oksigen (skor=3 bila SpO2 92%); hemoglobin (skor=4 bila anemia dan -6 bila normal), leukosit (skor=3 bila leukosit dan 0 bila normal). Total skor >3 Mempunyai sensitivitas dan spesifitas terbaik, yaitu 85,7% dan 72,1%. Kesimpulan. Skor prediksi kematian pneumonia >3 dapat digunakan untuk memprediksi kematian pada anak dengan pneumonia.

Latar belakang. Anak yang tinggal serumah dengan penderita TB paru dewasa berisiko tinggi untuk terinfeksi dan sakit TB. Pelacakan terhadap anak kontak serumah (contact screening) berpotensi menurunkan morbiditas dan mortalitas TB pada anak. Namun demikian, kegiatan itu belum rutin dilakukan di negara-negara endemis karena keterbatasaan tenaga dan fasilitas. Tujuan. Mengetahui faktor risiko sakit TB pada anak yang tinggal serumah dengan penderita TB paru dewasa Metode. Penelitian kasus kontrol pada anak usia ≤15 tahun yang tinggal serumah dengan penderita TB paru dewasa yang diobati di 18 Puskesmas, 2 balai pengobatan paru, dan 3 rumah Sakit di Kotamadya Yogyakarta antara bulan agustus 2010 dan Juni 2012. Kami melakukan anamnesis, pemeriksaan fisik, uji tuberkulin, dan foto Rontgen dada pada semua anak yang memenuhi kriteria inklusi dan eksklusi untuk menentukan ada tidaknya sakit TB. Dikatakan sakit TB apabila terdapat paling sedikit satu gejala TB dan foto Rontgen dada yang sugestif TB atau ditemukannya gejala dan tanda extrapulmonary TB. Hasil. Terdapat 126 anak, 21 sebagai kasus dan 105 sebagai kontrol. Karakteristik anak (usia balita (OR 1,94 95% CI (0,76–4,93), telah mendapatkan vaksinasi BCG (OR 1,09 95% CI (0,12–8,83)) karakteristik kasus indeks (derajat BTA sputum positif (OR 2,72 95% CI (0,76 -9,78), orang tua sebagai kasus indeks (OR 1,05 95% CI (0,42–2,67)) dan karakteristik lingkungan (polusi asap rokok dalam rumah (OR 1,07 95% CI (0,38–2,99) dan jumlah anggota keluarga >6 (OR1,85 95% CI (0,70–4,88) tidak berhubungan dengan risiko terjadinya sakit TB pada anak kontak serumah. Kesimpulan. Risiko kejadian sakit TB pada anak tersebut tidak berhubungan dengan karakteristik anak, kasus indeks, dan lingkungan yang diteliti.

Latar belakang. Salah satu faktor risiko kejang demam adalah riwayat kejang pada keluarga, dihubungkan dengan tipe kejang demam pertama dan usia saat terjadi kejang demam pertama. Beberapa penelitian menunjukkan riwayat kejang meningkatkan risiko kejang demam kompleks sebagai tipe kejang demam pertama dan berhubungan dengan usia kejang demam pertama yang lebih dini. Tujuan. Mengetahui hubungan riwayat kejang pada keluarga dengan tipe kejang demam pertama dan usia saat kejang demam pertama. Metode. Penelitian dilaksanakan di Bagian Ilmu Kesehatan Anak RSUP Dr. Sardjito,Yogyakarta sejak Januari 2009-Juli 2010. Pengambilan sampel dilakukan secara konsekutif dan dikelompokkan berdasarkan ada tidaknya riwayat kejang pada keluarga, tipe kejang demam pertama, dan usia saat terjadi kejang demam pertama. Hasil. Seratus lima puluh anak usia 6 bulan–5 tahun yang memenuhi kriteria inklusi dan eksklusi diikutsertakan dalam penelitian. Terdapat 91 (60,6%) anak yang mempunyai riwayat kejang pada keluarga dan kejang demam pertama terjadi pada usia yang lebih dini pada kelompok ini (median usia 13,0 vs 17,0 bulan; IK95%: 0,00-0,03; p=0,01). Anak dengan riwayat kejang lebih banyak mengalami kejang demam sederhana dibandingkan kejang demam kompleks (61,4% vs 59,2%), meskipun perbedaannya tidak bermakna (IK95%: 0,78-1,37; p=0,80) Kesimpulan. Anak dengan riwayat kejang pada keluarga cenderung mengalami kejang demam pertama pada usia yang lebih dini. Riwayat kejang pada keluarga tidak meningkatkan risiko terjadi kejang demam kompleks sebagai tipe kejang demam pertama.

Background Early discharging healthy term newborns results in a difficulty to recognize hyperbilirubinemia. Objective The aim of this study was to determine the value of the first 24-hour total and unbound bilirubin levels in predicting hyper- bilirubinemia in healthy term newborns. Methods The first 24-hour and the 5 th day total and unbound bilirubin levels were measured in 84 healthy term newborns. The total bilirubin level was measured spectrophotometrically, whereas unbound bilirubin level was determined by peroxidase-oxidation method. Hyperbilirubinemia was defined as serum total bilirubin of >12.9 mg/dL or serum unbound bilirubin of >0.5 mg/dL after 24 hours of life. Results A correlation between the first 24-hour and the 5 th day total bilirubin levels was found (r= 0.53) with a regression equa- tion: Y (total bilirubin on day 5) = 4.69 + 1.15X (total bilirubin in the first 24 hours). In unbound bilirubin (r=0.31), the regression equa- tion was Y (unbound bilirubin on day 5) = 0.13 + 0.95X (unbound bilirubin in the first 24-hours). The relative risk for developing hy- perbilirubinemia in newborns whose TB 1 was >4.5 mg/dL was 12 (95% CI 2.9;48.4), whereas newborns whose UB 1 was >0.09 mg/ dL was 9.5 (95% CI 1.2;77.4). Conclusion Total bilirubin level of >4.5 mg/dL in the first 24 hours can predict the development of hyperbilirubinemia in term new- borns in the first week of life. Newborns with such level of total bilirubin need a longer stay or should visit the hospital on day 5-7

Increasing attention is being given to the challenges of management and prevention of tuberculosis in children and adolescents. There have been a number of recent important milestones achieved at the global level to address this previously neglected disease. There is now a need to increase activities and build partnerships at the regional and national levels in order to address the wide policy-practice gaps for implementation, and to take the key steps outlined in the Roadmap for Child Tuberculosis published in 2013. In this article, we provide the rationale and suggest strategies illustrated with examples to improve diagnosis, management, outcomes and prevention for children with tuberculosis in the Asia-Pacific region, with an emphasis on the need for greatly improved recording and reporting. Effective collaboration with community engagement between the child health sector, the National Tuberculosis control Programmes, community-based services and the communities themselves are essential.

Indonesia has the third highest tuberculosis (TB) caseload internationally. A cornerstone for strengthening health systems to respond to TB is a well-trained workforce. In a partnership between Indonesian and Australian institutions, TB training was run during 2018 to strengthen the local capacity to meet End TB strategy targets. This paper aims to report on course design, delivery, training outcomes, and reflections. Seventy-six Indonesian healthcare workers, program staff, researchers, and policy-makers were selected from over 800 applicants. The structure comprised three trainings, each with a pre-course workshop (in Indonesia) to identify learning needs, a two-week block (Australia), and a post-course workshop (Indonesia). The training content delivered was a combination of TB technical knowledge and program/project theory, design, and logic, and the training utilised multiple teaching and learning methods. An innovative element of the training was participant-designed TB workplace projects focusing on context-specific priorities. Evaluation was undertaken using participant surveys and appraisal of the projects. Participants rated the course highly, while success in project implementation varied. Reflections include the importance of involving Indonesian experts in delivery of training, the need to understand participant learning requirements and adapt the training content accordingly, and the challenge of measuring tangible training outputs.

Background Delayed health care-seeking behavior is a cause of high mortality in children due to acute respiratory infections (ARis). Factors that may affect health care-seeking behavior are socioeconomic status, maternal age, maternal education, parents' perception of illness, child's age, number of children under five years of age in the family, and occurrence of natural disasters. The 2006 Central Java earthquake damaged homes and health care facilities, and led to increased poverty among the residents. Objective To assess the relationship between socioeconomic status and mother's health care-seeking behavior for children under five years of age with ARis in a post-earthquake setting. Methods This cross-sectional study used secondary data obtained from the Child Health Need Assessment (CHNA) survey. Logistic regression test was used to analyze variables that may affect mother's health care-seeking behavior for children under five years of age with ARis. Results Of the 665 infants surveyed, 442 infants (66.5%) had ARis. Health care-seeking behavior was good (81.7%) in the majority of mothers. We observed that socioeconomic status did not affect maternal health care-seeking behavior for children under five with ARis (OR 1.33; 95%CI 0.79 to 2.24; P= 0.26). Maternal age, maternal education, child's age and gender, number of children under five in the family, parents' perceptions of illness and severity of house damage caused by the earthquake also had no effect on maternal health care-seeking behavior for children with ARis. Conclusion After the 2006 earthquake, we find that socioeconomic status, maternal age, maternal education, child age, child gender, number of children under five in the family, parents' perceptions of illness, and severity of house damage have no effect on mother's health care-seeking behavior for their children with ARis.

Background Bronchiolitis peak incidence is in children aged 2 -6 months. History of atopy in parents, non-exclusive breastfeeding, exposure to cigarette smoke, and infants living in crowded areas may be risk factors for bronchiolitis. Gestational of age at birth is also influences the mortality oflower respiratory tract infection. Objective To evaluate the following conditions as possible risk factors for bronchiolitis: history of atopy, non-exclusive breastfeeding, preterm infants, exposure to cigarette smoke, and 2:: 6 persons residing in the home. Methods A sex-matched case-control study was conducted by collecting data from medical records at Sanglah Hospital, Denpasar. The case group subjects met the diagnostic criteria for bronchiolitis and were aged 1-24 months. The control group included patients with diagnoses unrelated to the respiratory system. Data was analyzed using bivariate (Mc.N emar) and multivariate methods (logistic regression) with 95% confidence intervals and statistical significance value of P

tuberculosis (TB) was developed to address the problem of overdiagnosis. The implementation of this scoring system in children who have household TB contacts has not been evaluated. Objective To evaluate the performance of the Indonesian pediatric tuberculosis scoring system in the context of contact investigation. Methods A cross-sectional study was conducted in the Yogyakarta municipality, between August 2010 and March 2011. Subjects were children under the age of 15 years, living in the same house with an adult who had pulmonary TB. Subjects underwent history taking, physical examinations, tuberculin skin tests (TST) and chest X-rays. Sputum smear was performed in symptomatic children. We compared outcomes of the Indonesian pediatric TB scoring system to that of rigorous clinical assessment. Results A total of 146 eligible children of 82 source cases were recruited into the study. Sixty-eight (47%) children had positive TST tuberculin skin tests. Using the scoring system, 47% of the subjects were diagnosed to have TB disease, while only 10% were diagnosed with TB using rigorous clinical assessment. With rigorous clinical assessment, 40% of the subjects were diagnosed as having latent TB infection (LTBI), while none of the subjects were diagnosed as LTBI using the scoring system. Conclusion The use of the Indonesian pediatric TB scoring system in children with household TB contact may lead to overdiagnosis of TB disease.

We sought to understand gaps in reporting childhood TB cases among public and private sector health facilities (dubbed "non-NTP" facilities) outside the network of national TB control programmes, and the resulting impact of under-reporting on estimates of paediatric disease burden and market demand for new medicines.Exploratory assessments were carried out in Indonesia, Nigeria and Pakistan, reaching a range of facility types in two selected areas of each country. Record reviews and interviews of healthcare providers were carried out to assess numbers of unreported paediatric TB cases, diagnostic pathways followed and treatment regimens prescribed.A total of 985 unreported diagnosed paediatric TB cases were identified over a three month period in 2013 in Indonesia from 64 facilities, 463 in Pakistan from 35 facilities and 24 in Nigeria from 20 facilities. These represent an absolute additional annualised yield to 2013 notifications reported to WHO of 15% for Indonesia, 2% for Nigeria and 7% for Pakistan. Only 12% of all facilities provided age and sex-disaggregated data. Findings highlight the challenges of confirming childhood TB. Diagnosis patterns in Nigeria highlight a very low suspicion for childhood TB. Providers note the need for paediatric medicines aligned to WHO recommendations.This study emphasises the impact of incomplete reporting on the estimation of disease burden and potential market size of paediatric TB medicines. Further studies on "hubs" (facilities treating large numbers of childhood TB cases) will improve our understanding of the epidemic, support introduction efforts for new treatments and better measure markets for new paediatric medicines.

Background. Screening of children who are household contacts of tuberculosis (TB) cases is universally recommended but rarely implemented in TB endemic setting. This paper aims to summarise published data of the prevalence of TB infection and disease among child contacts in South East Asia. Methods. Search strategies were developed to identify all published studies from South East Asia of household contact investigation that included children (0–15 years). Results. Eleven studies were eligible for review. There was heterogeneity across the studies. TB infection was common among child contacts under 15 years of age (24.4–69.2%) and was higher than the prevalence of TB disease, which varied from 3.3% to 5.5%. Conclusion. TB infection is common among children that are household contacts of TB cases in South East Asia. Novel approaches to child contact screening and management that improve implementation in South East Asia need to be further evaluated.