Active Tuberculosis Case Discovery Using the Adaptation Model in the City of Yogyakarta

and cross-sectors was prioritized in ACF. ACF was carried out 88 times with 7,423 participants; 1,403 people were suspected of having TB (18.90%), and 83 new TB cases were found. Most participants were women (54.41%), age group 55 - ≤65 years (23.19%), and came from the general public (56.31%). The highest percentage of suspected discoveries and TB cases came from the Pakualaman Health Center. Conclusion: With the adaptation model in Yogyakarta City, ACF contributed to finding 22.92% of suspected TB and 5.28% of TB cases of the target that had to be found. Collaborative efforts between sectors need to be made to mobilize the right target groups for ACF locations, such as PLHIV, household contacts, DM patients, toddlers with nutritional problems, groups of male smokers, and alcohol users


INTRODUCTION
Tuberculosis (TB) is a direct infectious disease caused by Mycobacterium tuberculosis.Until now, TB is still a problem at the global level; according to the World Health Organization (WHO), TB is one of the infectious diseases that causes the most deaths after Covid-19.WHO data states that there will be 1.6 million deaths due to TB in 2021 (WHO., 2023).Indonesia is one of the countries with the highest TB burden in the world, with the second highest number of TB cases after India (WHO, 2022).The high burden of TB problems at the global level has encouraged the formation of an agreement at the world level, which is outlined in the Sustainable Development Goals (SDGs) targets, one of the targets of which is to end the TB epidemic by 2030 by reducing the global TB incidence by up to 80% and reducing the number of deaths due to TB throughout the world.It is up to 90% compared to 2015 (StopTB Partnership., 2022).
Yogyakarta City is one of the districts/cities in D.I.Yogyakarta with the highest estimated TB caseload after Sleman and Bantul Regencies (D.I.Yogyakarta, 2023).The COVID-19 pandemic in 2020-2021 greatly affected the achievements of the TB program globally and nationally.This condition is also experienced by almost all districts/cities in Indonesia, including Yogyakarta.Data on TB case detection reported in the Yogyakarta City Tuberculosis Information System (SITB) in 2020 and 2021 decreased by 22% compared to 2019, and in 2022 it increased by 23.49%.1,355 TB cases were discovered and treated in 2022 (Dinas Kesehatan Kota Yogyakarta., 2023).
By the mandate in Presidential Regulation Number 67 of 2021 concerning Tuberculosis Control, the Indonesian Government has established strategies and interventions to accelerate the elimination of TB by 2030.The Indonesian Ministry of Health has developed a framework for accelerating the TB program in the form of active case finding (ACF), strengthening surveillance, and expanding the delivery of tuberculosis prevention therapy (TPT) (Kementrian Kesehatan RI., 2022).The Yogyakarta City Government's commitment to supporting the achievement of TB elimination by 2030 through collaboration of all sectors in TB control is stated in Yogyakarta Mayor Regulation Number 7 of 2023 concerning the Yogyakarta City TB Control Regional Action Plan (Dinkes Kota Yogyakarta, 2023).
ACF activities in Yogyakarta City are one of the efforts to eliminate TB by finding TB cases as early as possible and providing complete treatment.ACF has been carried out since 2020 with support from Zero TB (ZTB) Yogyakarta with a screening model for at-risk groups using chest X-rays or mobile chest X-rays (CXR).In 2020, ACF activities in Yogyakarta City took the form of a pilot project in the Gondomanan Kemantren area, then in 2021 to 2022, ACF activities began to be developed in 14 Yogyakarta City areas using a scale-up modeling approach.In 2023, ACF activities with CXR will be developed as an adaptation model.This research was conducted to obtain an overview of the results of ACF activities in Yogyakarta City using an adaptation model to be used as evaluation material for implementing the TB control program in Yogyakarta City.

LITERATURE REVIEW
ACF is an accelerated program to increase the discovery of undetected TB cases through active efforts to look for people who are at risk, have symptoms, and carry out detection (Mulya, 2023).Active TB case finding can be done through contact tracing (contact investigation) to identify people with a history of close contact with TB patients and examine them to determine whether they may have been infected with TB germs.Another effort to actively find TB cases is with a screening model that aims to identify individuals who are at high risk of being infected with TB.ACF is essential to carry out considering that based on studies analyzing the course of TB patients, not everyone who has experienced TB disease will immediately seek treatment; this is because the patient has not felt any symptoms of illness.Another reason why TB suspects do not go to health service facilities is due to a lack of knowledge and difficult access in urban areas with easy access to health facilities and guaranteed funding.Mismatches in service times can also be the cause of people who are sick with TB not wanting to go to health facilities (JDIH Pemerintah Kota Yogyakarta., 2023).ACF activities in high-risk populations can increase TB detection in the early phase, where TB symptoms are not yet felt, as well as reduce the problem of difficulties in access and service times at health facilities (JDIH Pemerintah Kota Yogyakarta., 2023).
ACF using CXR screening has been recommended to find TB early during the disease.The presence of radiological abnormalities suggestive of TB as a result of CXR can be immediately identified even before it becomes active TB (Mac et al., 2020).It is hoped that ACF with CXR screening will increase TB case detection.CXR screening results that show lung abnormalities suggestive of TB will be followed up with laboratory supporting examinations to confirm the diagnosis of TB (Murakami et al., 2016).
With an adapted model, ACF combines TB symptom screening and CXR screening in high-risk populations by strengthening the role of Community Health Centers and crosssectors.The flow of ACF activities in the adapted model begins when participants come to the ACF location.After registering, participants will undergo screening for TB symptoms and screening with CXR.Based on the results of symptom screening and CXR, participants who are diagnosed with suspected TB will be initiated to collect sputum samples for TCM examination in the laboratory.The results of the TCM and CXR examinations will be the basis for consideration by the Puskesmas Doctor in determining a TB diagnosis.TCM inspections follow the referral flow for TCM inspections according to the zoning that is in effect in the City of Yogyakarta.According to TB treatment management at the community health center, ACF participants diagnosed with TB will be followed up.

METHOD
The method used in this research is quantitative descriptive.The variables studied included ACF participants' characteristics, target group type, CXR screening, Rapid Molecular Test (TCM) examination, and the contribution of ACF activities in the TB control program.The data used in this research is secondary data in the P2M and Immunization section of the Yogyakarta City Health Service in the form of reports on the results of ACF TBC Puskesmas activities to the Yogyakarta City Health Service from January to June 2023.The collected data was analyzed descriptively to describe the implementation of ACF TBC using the adaptation model; the results of the analysis are presented in tables and narratives.This research has received ethical approval number 012308163, granted by the Ahmad Dahlan University Yogyakarta Research Ethics Committee (KEP UAD).

RESULT AND DISCUSSION
In 2023, the implementation of ACF activities in the City of Yogyakarta will change from a scale-up model to an adaptation model.Several changes to the adaptation model in implementing ACF activities are described in Table 1.
In the ACF with the adaptation model, the role of community health centers and cross-sectors in the Ministry of Education and Culture is prioritized.The Community Health Center is responsible for the overall implementation of ACF activities, starting from the preparation stage (determining the schedule, location, and target group), implementation stage, and follow-up to ACF activities, including sending sputum samples to the TCM Laboratory, reading Tuberculin Skin Test (TST) results, preparing case discussion materials, determination of diagnosis and initiation of TPT administration.Human resource support from the Yogyakarta ZTB Team is the ACF Team, which consists of district coordinators, doctors, screening nurses, registration officers, and radiographers.An overview of the results of the ACF adaptation model activities based on participant characteristics, target groups, CXR examinations, TCM examinations, and the contribution of ACF activities in the TB Control Program is detailed as follows:

Participant Characteristics
The distribution of ACF participants based on the detailed characteristics in Table 2.

Target group of ACF participants
Based on the ACF target group, more than half of the participants came from the community around the location of the ACF, namely 4,180 people.

CXR examination of ACF participants
In Table 4, it is known that most of the participants took part in screening with CXR to determine the radiological appearance of the lungs, and only 3.26% of participants did not undergo a chest X-ray examination for various reasons, including having had a CXR examination within the last six months.

TCM examination on suspected TB
After ACF participants undergo screening with CXR, the results of radiological readings of chest X-rays that suggest suspected TB will be followed up by examining sputum samples with TCM examination.The number of TB suspects found in ACF activities was 1,403; however, 22.24% of participants had not undergone a TCM examination (Table 5) because they could not produce phlegm at that time.

Discovery of new TB cases based on TCM examination results
Based on the results of the TCM examination and reading of the CXR results, diagnosed TB cases are divided into bacteriologically confirmed if the TCM results show that Mycobacterium tuberculosis (MTB) was detected and clinically confirmed if the TCM results show that MTB was not detected.The CXR reading results show that the lungs are positive for TB.Most TB cases found were clinically confirmed; one of the objectives of screening with CXR is to find TB cases early or in the early phase (sub-clinical) of TB disease.

Discovery of TB cases based on the target group of ACF activities
Table 7 shows that most participants in ACF activities are in the community around the location where ACF activities are held.However, unexpected findings and TB cases from this target group are relatively small (0.74%).In contrast, for PLHIV, the number of participants taking part in the ACF was only 79 people, with the discovery of suspected TB and TB cases in the PLHIV group being relatively high (7.59%).The ACF adaptation model activity found 22.92% of TB suspects and 5.28% of TB cases from the target set in Yogyakarta City in 2023.ACF participants were dominated by women aged 55-≤ 65 years.One of the risk factors for TB disease shows that men are more at risk than women, but the number of men who take part in ACF is smaller.Data on TB cases in Yogyakarta City shows that TB cases in men are higher than in women (Dinas Kesehatan Kota Yogyakarta., 2023).In ACF TBC activities in Yogyakarta City, mobilizing male participants tends to be more difficult than mobilizing women.This condition could be because ACF activities are carried out during working hours, so more women who are not working have time to attend ACF TBC activities.This result is different from the results of ACF activities carried out in Myanmar, which showed that there were more male participants (61.3%) than female participants (38.7%) (Myint et al., 2017).
The timing of the ACF also influences the age group of participants.ACF is held Monday to Friday, starting at 08.00 WIB to 14.00 WIB, which is the time used by productive age groups for work or school/college, so they cannot come to the ACF location.In contrast to ACF activities in Myanmar, ACF participants are attended mainly by participants of productive age (aged 15-54 years) (Myint et al., 2017).
One of ACF's goals with the adaptation model is to bring CXR screening services closer to the community.For groups of people who are reluctant to come to health facilities, taking part in ACF activities can be an option to get a beneficial health check because in ACF with the adapted model, apart from checking TB symptoms and CXR examinations, Non-Communicable Disease (PTM) screening checks are also carried out such as blood pressure and sugar checks.Determining the target group of ACF participants is an important thing that must be prepared so that ACF activities are suitable on target (Murakami et al., 2016).Apart from that, ACF activities are also integrated with TB patient contact investigation activities.Household contacts are one of the target groups in ACF activities.In household contacts of TB patients, visits to the location where the ACF is held, apart from the CXR examination, TST examination is also carried out as a consideration for the Puskesmas Doctor to determine the provision of TPT (Zero TB Yogyakarta., 2022).
The use of CXR for TB screening activities is considered more sensitive than screening using a symptomatic approach because the majority of diagnosed TB patients are known not to have typical TB symptoms (Ho et al., 2016).The research results in Uganda show that screening results with CXR have a sensitivity of 93% and a specificity of 65% compared to the results of culture of sputum samples (Nalunjogi et al., 2021).According to Dina Bisara, in her Inauguration Oration for Research Professors in the Health Sector (2022), Thorax Photos and TCM are technologies that can be used to increase the discovery of TB cases (Dina Bisara Lolong, 2022).n ACF activities with the adapted model, apart from CXR examinations, screening by asking about TB symptoms such as coughing, fever, night sweats, weight loss, and TB risk factors is still carried out.The combination of these screening results will be considered by health center doctors in diagnosing TB (Basem Abbas Al, 2018).
TCM examination is recommended as a laboratory test to confirm the diagnosis of TB (Ritonga et al., 2023).ACF participants with symptom screening and CXR results that suggest TB is suspected will be followed by an examination of sputum samples to confirm the diagnosis of TB.Some TB suspects have not had a TCM examination during the ACF activity due to difficulty expelling phlegm, even though they have been motivated and educated by officers at the ACF location about how to cough effectively.The ACF organizers have provided sweet tea to stimulate coughing so that phlegm can be expelled; however, for some participants, coughing up phlegm is still an obstacle.This condition is similar to the results of research conducted in Semarang in 2019, showing that several TB patients could not collect sputum samples because they could not produce phlegm (Masitah, 2022).
In research conducted in Yunnan Province, China, it was concluded that massive ACF activities in the community were ineffective ACF activities (Chen et al., 2019); this condition also happened in ACF activities with an adaptation model in Yogyakarta City, coverage of TB case discovery those from the surrounding community are still low (0.74%).The highest TB case detection coverage from the results of ACF activities came from the PLHIV target group (7.59%), followed by household contacts (2.81%), health center visitors (2.77%), and DM patients (1.13%).This data is the results of research conducted by Jenifer Ho et al. l (2016) selecting the right population as the target group for screening on ACF, such as household contacts and risk groups such as PLHIV, DM patients, malnutrition, Active Tuberculosis Case Discovery Using the Adaptation Model in the City of Yogyakarta (Setyogati Candra Dewi et al) smoking history, alcohol dependence are groups who are at high risk of contracting TB disease, so ACF activities are prioritized targeting this group to obtain significant results (Ho et al., 2016).When compared with the target for finding TB suspects (11th SPM in the health sector) and the target for finding TB cases in each ACF Organizing Community Health Center, which are listed in Table 8, the highest number of TB suspects found came from the Umbulharjo I Community Health Center as many as 147 people and the cases discovered.The most TB came from the Jetis and Pakualaman Community Health Centers, each finding 13 TB cases.However, compared with the SPM target and the target for finding TB cases at each community health center, the highest percentage of suspected TB cases and discoveries was at the Pakualaman Community Health Center, namely 69.23% for finding suspected TB and 32.50% for finding TB cases.Pakualaman Community Health Center held TB ACF in the working area of the community health center three times.It held TB ACF in prisons and detention centers, which are included in the working area of Pakualaman Community Health Center 7 times.The achievement of finding suspected TB and TB cases at the Pakualaman Community Health Center from ACF TBC activities cannot yet reflect the high number of TB cases in the Pakualaman Community Health Center area, considering that most of the TB cases found came from prisons and detention centers which are closed populations.There needs to be more interaction with the outside community in the Pakualaman area.The research results by Gupta (2018) concluded that vulnerable groups, including prisoners, were the main priority in controlling TB (Gupta et al., 2018).

CONCLUSION
With an adaptation model in the City of Yogyakarta, ACF contributed to finding 22.92% of the target for finding TB suspects and 5.28% of the target for finding TB cases in the City of Yogyakarta in 2023.Collaborative efforts between sectors need to be made to mobilize the right target groups to ACF locations so that they can increase TB cases, such as PLHIV, household contacts, DM patients, toddlers with nutritional problems, groups of male smokers, and alcohol users.

Table 1 .
Financing for ACF activities in the adaptation model is supported by Yogyakarta City APBD funds for 2023 and Zero TB Yogyakarta.Logistics to support ACF activities, such as sputum pots, Mantouxtest reagents, and other consumable materials, are provided by the P2TB Program of the Yogyakarta City Health Service with a distribution mechanism through each ACF Organizing Community Health Center.Management of medical waste resulting from ACF activities follows the medical waste management mechanism at each ACF Organizing Community Health Center.Adaptation model ACF activities were held 88 times with a total of 7,423 ACF participants.ACF Model in Yogyakarta City 2021-2023

Table 2 .
Proportion of ACF Participants based on gender and age(N= 7.432) Based on gender, more than half of ACF participants are women-dominated.Meanwhile, based on age, almost a quarter of the most prominent participants were in the age group 55-≤65 years, and the fewest participants were in the age group less than five years.

Table 4 .
Proportion of ACF participants based on CXR examination(N= 7.432)

Table 5 .
Proportion of suspected TB based on TCM examination(N= 7.432)

Table 6 .
Discovery of TB cases resulting from ACF activities(N= 7.432)

Table 7 .
Results of TB case discovery based on target groups(N= 7,432) Active Tuberculosis Case Discovery Using the Adaptation Model in the City ofYogyakarta  (Setyogati Candra Dewi et al)

Table 7 .
Results of TB case discovery based on target groups (N= 7,432) (continued) Suspected findings and TB cases from the implementation of the ACF adaptation model compared with the target of alleged findings and TB cases that each Community Health Center has determined are presented in Table8.