Malaysian Journal of Public Health Medicine 2020, Vol.

20 (1): 192-198

ORIGINAL ARTICLE

HAVING CONTACT HISTORY WITH TB ACTIVE CASES AND MALNUTRITION AS

RISK FACTORS OF TB INCIDENCE: A CROSS-SECTIONAL STUDY IN NORTH
SUMATERA, INDONESIA
Wiwit Aditama1*, Frans Yosep Sitepu2** and Elpiani Depari3

1Department of Environmental Health, Banda Aceh Polytechnic of Health of the Ministry of Health, Indonesia
2Provincial
Health Office of North Sumatera, Indonesia
3GrandMed Hospital, Deliserdang, North Sumatera, Indonesia

Corresponding author 1: Wiwit Aditama

Email: [email protected]
Corresponding author 2: Frans Yosep Sitepu
Email: [email protected]

ABSTRACT

Tuberculosis (TB) is one of the leading causes of morbidity and mortality. It is carrying a heavy public health problem
burden in Indonesia. This study aimed to determine the risk of poor knowledge of TB, socioeconomic status,
malnutrition and contact history with TB cases with the incidence of TB in Medan. This was a cross sectional study
conducted between May – August 2019 in Medan municipality, in the three highest TB cases incidence public health
centers (puskesmas). Structural interviews were conducted to solicit demographic data, clinical data, as well as the
risk factors. Logistic regression was conducted to assess the potential risk factors associated with the infection. We
enrolled 260 clinically suspected cases of TB, comprising 135 (51.9%) cases positive for TB and 125 (48.1%) cases negative
for TB. In multivariate model, those who had contact history with active TB cases and those who malnourished had
higher odds of having TB infection, with adjusted odds ratio (aOR): 5.58 (95%CI:3.13–9.93) and aOR: 3.36 (95%CI: 1.87–
6.02), respectively. Having contact history with TB active case and malnutrition were the most significant risk factors
of TB incidence in Medan municipality, North Sumatera, Indonesia. Therefore, educating patients on the importance
of cough or sneezes etiquette procedures including use of face masks to minimize the risk of infection.

Keywords: contact history, malnutrition, TB, cross sectional

INTRODUCTION 91.2% (national target was >95%). Medan

municipality is the capital of North Sumatera
Tuberculosis (TB) is a communicable disease that province and the highest TB incidence in the
caused by the bacillus Mycobacterium province. Medan is the third largest city in
tuberculosis.(1,2) According to the world health Indonesia with the number of population more
organization (WHO), TB is a major public health than 2.2 million people. Medan municipal
problem and one of the greatest threats in the government is fully committed in the prevention
world. It is one of the top 10 causes of death (1) of TB in the city. This commitment is outlined in
and estimated that about a quarter of the world’s Medan Mayor Regulation (Peraturan Walikota)
population is infected with Mycobacterium No.85 / 2017 concerning TB Prevention in
tuberculosis and thus at risk of developing the November 2017. TB cases in Medan which were
disease. discovered and reported from 2013 to 2016 were
5,333 cases; 5,773 cases, 6,421 cases, and 7,431
TB is one of the major causes of morbidity and cases respectively. While multidrug resistant TB
mortality in Indonesia carrying a heavy public cases to date were 299 cases.(6,7)
health problem burden.(3–5) Indonesia is one of the
eight countries accounted for two thirds of the However, TB is still a health problem and found in
global total TB cases in the world. The country all areas of the public health centers (puskesmas).
also ranks ninth amongst the 20 high burden TB The scope of the causes of TB problems in Medan
countries with TB incidence rate of 341 per is very multi-factor such as the low level of
100,000 populations, however, only 45% of these community knowledge, socioeconomic status,
cases are detected and reported to the National malnutrition and having contact history with
TB Program (national target was 70%).(3) pulmonary TB sufferers. Having contact history
with TB cases was risk factor for TB. Household
In North Sumatera province, the case detection contacts are highly susceptible to acquire TB
rate (CDR) was only 50%, and success rate (SR) was infection from the index cases because of their
Malaysian Journal of Public Health Medicine 2020, Vol. 20 (1): 192-198

close proximity.(8,9) Many studies have concluded calculated BMI as weight in kilograms divided by
that malnutrition increases the risk for TB the square of height in meters. If the result is
infection because of impaired immune underweight (BMI < 18.5) or overweight (BMI > 25)
response.(1–3) the respondent will be grouped into malnutrition.
Socioeconomic status by measuring the monthly
income of the respondents compare with the
This study aimed to determine the risk of poor regional minimum wage of Medan municipality. If
knowledge of TB, socioeconomic status, the respondent’s monthly income was below the
malnutrition and contact history with TB cases regional minimum wage of Medan it will be
with the incidence of TB in Medan. grouped into low socioeconomic status. Contact
METHODS history measuring by asking the respondents with
close contact history with TB cases in the
Study design and setting household, schools, or working places.

This was a cross sectional study conducted During the study period there were 260 suspected
between May – August 2019 in Medan municipality. TB patients who came to the study sites. Sputum
The city is the capital of North Sumatera province. samples were collected from all the suspected
The study was conducted in the three public cases by trained laboratory assistant. The
health centers (PHC) with highest TB incidence in standard procedures on the collection of sputum
Medan municipality: Medan Area Selatan PHC, sample for TB suspect cases (i.e. spot- early
Glugur Darat PHC and Teladan PHC. morning - spot). Spot sample was collected at the
time of first visit of patient to the PHCs and early
Study procedures morning sputum was collected the next day.

All clinically suspected cases of TB who came to Data analysis

the three PHCs during the data collection period
were interviewed. Face to face interview were Variables associated with TB in the univariate
conducted to all the respondents. A structured analysis (p< 0.05) were included for the
questionnaire consisting of respondent multivariate analysis. A 95% confidence interval
characteristics and demographic information was and a 5% level of significance were used to
used. Respondent related information contained interpret statistical significance. The p-values <
age, gender, knowledge of TB and its prevention, 0.05 were considered significant. In the
nutritional status, socioeconomic status and multivariate analysis, we included the knowledge
history of contacts with TB cases. To measure the of TB variable because it is one of the major
knowledge regarding TB, the questions according independent variables of the present study.
to the guideline of prevention and control of TB
by the Ministry of Health of Indonesia. Ethical considerations

The respondents’ knowledge score about TB was Health research ethics commission of Banda Aceh
calculated as the sum of the response scores. The Polytechnic of Health of the Ministry of Health,
number of questions regarding the respondent's Indonesia (Ref No LB.02.03/10267/2019)
knowledge was 20 questions. Each correct approved the project protocol and
respondent's answer will get a score of 1 (one) and questionnaires. Written informed consent was
0 (zero) for each incorrect/unknown answer. The obtained from all participants.
minimum score of the respondent is 0 (zero) and
20 for the maximum score. The level of knowledge RESULTS
was grouped into "adequate" and "inadequate"
based on the 80% cut-off point. The Cronbach’s Characteristics of subjects
alpha coefficient of the knowledge questionnaire
was 0.75 in our sample, indicating acceptable We enrolled 260 clinically suspected cases of TB,
internal consistency. comprising 135 (51.9%) cases positive for TB and
125 (48.1%) cases negative for TB. There was no
Nutritional status counted by measuring the body significance difference in characteristics of
mass index (BMI) of the respondents. We subjects (Table 1).
Malaysian Journal of Public Health Medicine 2020, Vol. 20 (1): 192-198

Table 1. Characteristic of subjects (n=260)

Variables TB (%) Not TB (%) p-value

Gender
Male 73 (54.1) 56 (44.8) 0.41
Female 62 (45.9) 69 (55.2)

Age group
20-30 year 32 (23.7) 41 (32.8) 0.68
31-40 year 51 (37.8) 58 (46.4)
>40 year 52 (38.5) 26 (20.8)

Level of education
Primary 35 (25.9) 23 (18.4) 0.53
Secondary 68 (50.4) 70 (56.0)
Tertiary 32 (23.7) 32 (25.6)

Occupation
Businessman 55 (40.8) 43 (34.4) 0.64
Employee 28 (20.7) 26 (20.8)
Housewife 52 (38.5) 56 (44.8)

Table 2. Association between knowledge of TB, socioeconomic status, malnutrition and contact
history with TB incidence

Variables TB Not TB p-value OR 95% CI

Knowledge of TB
Inadequate 75 72 0.84 0.92 (0.56 - 1.50)
Adequate 60 53

Socioeconomic status
Low 73 41 0.01 2.41 1.46-3.99
High 62 84

Malnutrition
Yes 100 46 0.01 4.91 2.89 - 8.33
No 35 79

Contact history
Yes 95 31 <0.01 7.20 4.16 - 12.47
No 40 94

Table 3. Multivariate analysis of risk factors of TB incidence

Variables B p-value OR 95% CI

Malnutrition 1.21 0.01 3.36 1.87 - 6.02
Contact history 1.72 <0.01 5.58 3.13 - 9.93
Malaysian Journal of Public Health Medicine 2020, Vol. 20 (1): 192-198

DISCUSSIONS between TB and socioeconomic conditions, but no

direct cause and effect relationship has been
In this study we found that the risk factors of TB demonstrated. It appears that although poor
incidence in Medan were having contact history people have a higher risk of becoming infected,
with TB cases and malnutrition. Having contact there is no direct evidence that the infected poor
history with TB cases was the strongest risk factor have a higher risk of developing disease.(2,5,16,21)
for TB incidence in the study. TB contacts were
people who had close contact for any length of In addition, another risk factors of TB incidence
time with active TB case. A close contact of a were physical conditions of house environment
person with active TB has a high risk of becoming such as ventilation, lighting, occupancy density,
infected and developing of the disease. The risk humidity, temperature and type of floor.(22) Low
of TB infection is greatest if the contact is close socioeconomic status was related to not eligible
and prolonged.(10,11) TB contacts should be of physical conditions of house environment. Many
investigated systematically and actively to studies found that a poor physical conditions of
prevent TB infection in the community.(9,12,13) house environment can become a way for disease
transmission. It is because the high intense
When there is a TB case it can increase risk of TB interaction between humans and the
to other members of the household.(10,11,14) TB is environment, especially for people who spend a
transmitted from person to person through the lot of time at home.(8,16,23) However, we did not
air. The Mycobacterium tuberculosis is carried in investigate the physical conditions of house
airborne particles, after exposure to airborne the environment of the respondents. Therefore, this
droplets some contacts will be infected and some was the limitation of the study.
of these will go on to develop the disease.(10,15)
The study revealed that the cases had contact Finally, as the result of the study we could not
history with TB active cases. Therefore, educating find the relationship between knowledge of TB
patients on respiratory hygiene and the and TB incidence. However, we found that 147 out
importance of cough or sneezes etiquette of 260 (56.54%) respondents were inadequate
procedures including use of face masks to knowledge of TB. Respondents’ knowledge of TB
minimize the risk of infection.(15) This findings is is an important variable. Inadequate respondents’
consistent with previous studies that have knowledge of TB causes not only the delay in
demonstrated an association between having seeking diagnosis but also poor treatment
contact history with TB cases and the incidence of adherence.(1,4) The relatively poor knowledge of
TB.(8,9,11,12,14,16) TB among the respondents showed that there is a
need to implement activities that would educate
Malnutrition was another risk factor of TB the public about the disease.
infection.(2,16–18) The association between
malnutrition and TB incidence is bi-directional. TB CONCLUSIONS
predisposes the patient to malnutrition and
malnutrition increases the vulnerability of We can conclude that having contact history with
developing the disease.(18,19) Epidemiological TB active case and malnutrition were the most
studies have shown that malnutrition affects significant risk factors of TB incidence in Medan
genetic expression and impaired immune municipality, North Sumatera, Indonesia.
response, which are predisposing factors for Therefore, educating patients on the importance
tuberculosis progression. (2,16,18) Malnutrition is of cough or sneezes etiquette procedures
one of important risk factors for TB because it including use of face masks to minimize the risk
profoundly affects cell-mediated immunity (CMI). of infection.
It is a condition when an immune response that
does not involve antibodies; CMI also the principle ACKNOWLEDGMENT
host defense against TB.(18,20) This finding is
consistent with other studies where individuals We would like to acknowledge to the head and all
who malnourished had a higher risk of acquiring the TB program staffs of Medan Area Selatan PHC,
TB infection compared to those who not Glugur Darat PHC, Teladan PHC, and all the
malnourished.(2,17–19) participants for their significant contribution.

In the multivariate analysis we found that CONFLICT OF INTEREST

socioeconomic status was not related to TB
incidence. However, in the bivariate analysis The authors declare that they have no competing
socioeconomic status was related to the incidence financial interest. This is a self-funded research.
of TB. As much as 73 out of 135 (54.07%) TB cases
were low socioeconomic status. People with low
socioeconomic status have a higher risk of being
infected and a higher incidence of TB. Most
researchers agree on the general association
Malaysian Journal of Public Health Medicine 2020, Vol. 20 (1): 192-198

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