A tuberculosis patient

Every case of active TB disease comes from those who are infected with the TB bacteria (referred to as latent TB infection). Additionally, the top-5 TB risk factors — malnutrition, tobacco use, alcohol use, diabetes and HIV— increase the risk of progressing from latent TB to active TB disease manifold. these risk factors also make it difficult to treat TB, and risk of death also shoots up, says Dr Guy Marks, President of the International Union Against Tuberculosis and Lung Disease (The Union).

Indonesia's Minister of Health Budi Gunadi Sadikin called for stronger actions to end all forms of tobacco smoking in the country to progress towards ending TB. Tobacco smoking is the biggest preventable cause of not only TB but also several other life-threatening diseases in Indonesia, as well as globally. He was delivering the keynote address at the Indonesia National Webinar on the theme "Yes! We can end TB and tobacco smoking," co-hosted a day before World Health Day 2023 by Indonesia’s Ministry of Health, All Indonesia Public Health Services Association (ADINKES), Indonesian TB Research Network (JetSet TB), International Union Against TB and Lung Disease (The Union) and Asia Pacific Cities Alliance for Health and Development (APCAT). This almost 5-hours long virtual session was attended by 1000 people from diverse government ministries, departments and other sectors from Indonesia, Nepal, India, Singapore, and other countries in Asia Pacific region.

According to the latest Global TB Report 2022 of the World Health Organization (WHO), Indonesia has the second highest TB burden in the world after India. There were 969,000 estimated TB cases in Indonesia in 2021, out of which 74% (717,941) were notified to the national programme. Over half of TB cases (53%) were males (in whom smoking rates are higher too).

More alarmingly, the WHO report points out that the top-5 TB risk factors in Indonesia in 2021 were: undernourishment (which caused 120,000 new TB cases), tobacco smoking (which caused 113,000 new TB cases), HIV (which caused 35,000 new TB cases), diabetes (which caused 28,000 new TB cases), and alcohol (which caused 14,000 new TB cases).

The WHO report also tells us that in 2021 these were also the top 5 TB risk factors in the whole of Asia Pacific region: undernourishment (1.2 million new TB cases), tobacco use (502,000 new TB cases), alcohol (486,000 new TB cases), diabetes (234,000 new TB cases), and HIV (209,000 new TB cases).

To End TB We Have to End Tobacco

"We cannot end TB unless we end tobacco smoking," said Mukta Sharma of WHO. It is important to note that whether a person is smoking tobacco or exposed to passive smoking, the risk of TB disease goes up by 6 to 9 times. "In Indonesia, 77% of TB patients were smokers — much higher than other countries in the region," said Sharma.

Dr Ayu Swandewi Astuti, from Udayana University in Indonesia emphasised that efforts to end TB must be in tango with efforts to end tobacco smoking, alcohol consumption and undernourishment; prevent diabetes; and ensure that every person with HIV is receiving the full cascade of HIV care services.

“In Indonesia and the 30 countries with the highest TB burden, men are at higher risk of TB than women because most (60%) men aged over 15 years smoke cigarettes,” said Indonesian Health Minister Budi Gunadi Sadikin.

Instead of Declining, Tobacco Smoking Has Increased in Indonesia

“In the last 10 years, the number of adult smokers in Indonesia has increased significantly by 8.8 million - from 60.3 million smokers in 2011 to 69.1 million smokers in 2021. The results of the Global Adults Tobacco Survey (GATS) also show a 10-fold increase in the prevalence of electronic smoking- from 0.3% in 2011 to 3% in 2021. Meanwhile, the prevalence of secondhand smoke has also risen to 120 million people,” said Sadikin.

Studies show that tobacco smokers are at 2-3 times higher risk of TB disease progressing from latent TB to active TB disease; treatment outcomes are less optimal and risk of death is also higher in them. Having non-communicable diseases (NCDs) like diabetes further elevates the TB risk. “TB is one of the leading causes of death in smokers, with 15.2% of deaths from TB related to smoking, so smoking as a major risk factor for TB can hinder the target of reducing TB incidence and mortality by 2030,” said Sadikin.

According to the Institute for Health Metrics and Evaluation (IHME), TB is the 10th leading cause of death in Indonesia at 7.1%, after heart disease, cancer and diabetes. Also, at 17.03% smoking is the second highest risk factor for death after cardio vascular disease.

That is why strong coordinated actions are an absolute must to end both — TB and tobacco smoking — along with prevention of NCDs, and promotion of other health activities. “It is necessary to strengthen the strategy in supporting the achievement of National Medium term Development Plan (RPJMN) 2020-2024 to reduce the prevalence of smokers aged 10-18 years and eliminate TB in Indonesia,” Sadikin said. He called for stronger implementation of a range of evidence-based tobacco control measures, such as ban on smoking in public places, quit-tobacco-smoking services to help people (and TB patients) to quit the addiction, among others.

Sadikin also shared that during COVID-19, the number of people who could get diagnosed with TB in a year had dipped to around half a million but in 2021 it again picked up to over 717,000. But, over 200,000 people were missing from TB care services in 2021. He underlined the importance of reaching out to everyone with TB disease with the full cascade of health services, and ensuring that everyone is on treatment. In 2021, 86% of those who were diagnosed with drug-sensitive TB were put on treatment, out of which 87% reported treatment completion in Indonesia. However, only one-third of those with drug-resistant TB were put on treatment in the same year. Sadikin called for ensuring every person with TB should get full cascade of services if we are to end TB.

“TB is preventable. Each of the 969,000 people who got TB disease in Indonesia in 2021, is a grim reminder that we could have done better to prevent TB. If we are to end TB by 2030 we also need stronger actions against risk factors that put people at risk of TB. For example tobacco use is entirely preventable, but sadly continues to be a major risk factor for not just TB but also NCDs,” said Dr Tara Singh Bam, Asia Pacific Director of The Union and Board Director of APCAT.

"We have to find everyone with TB in our community and ensure that full spectrum of TB services are within reach of the person. As tobacco smokers are many times more at risk of TB (and several other deadly diseases), government must implement comprehensive tobacco control policies as per the WHO recommendations. These include higher taxes and prices on tobacco products, effective ban on all forms of tobacco advertising, promotion and sponsorship, increasing pictorial health warning on tobacco packs to over 90% size, complete ban of smoking in public places and workplaces, among others. When we do TB budget allocation at village level then we also need to couple it with budget allocation for full range of evidence-based tobacco control," added Dr Bam.