GRAPHICAL ABSTRACT

INTRODUCTION

Indonesia has the second-highest number of tuberculosis (TB) cases globally, after India. The estimated TB incidence in Indonesia is 1 090 000 cases (387 cases per 100 000 population), with an associated mortality of 131 000 deaths (47 deaths per 100 000 population) [1]. The global commitment to ending TB is outlined in the End TB Strategy, which aims to reduce TB deaths by 90% by 2030 and TB incidence by 80% by 2035, while ensuring that no household experiences catastrophic costs due to TB by 2030 [2]. According to the World Health Organization, an estimated 1.25 million children aged 0–14 years developed TB in 2022, accounting for approximately 12% of the global TB burden [3]. Globally, the proportion of TB cases occurring in children ranges from 11% to 12% [4]. In Indonesia, children accounted for approximately 9% of all confirmed TB cases [2]. Notably, the number of TB cases in children younger than 15 years increased sharply from 42 187 in 2021 to 110 881 in 2022, with the highest incidence observed among children aged 0–4 years [5]. Diagnosing TB in children is challenging due to the wide variation in clinical presentations and the difficulty of obtaining sputum samples for testing [6].

Although children are less likely to transmit TB than adolescents and adults, they are at greater risk of progressing to active disease and developing severe forms of TB, particularly those younger than 5 years and those who have not received Bacillus Calmette-Guérin (BCG) vaccination [7,8]. Diagnosing TB in children remains difficult because of challenges in obtaining sputum samples and limited access to sensitive diagnostic tests, which contribute to under-reporting [9]. In addition, not all health facilities report TB cases to the National TB Surveillance System (Sistem Informasi Tuberkulosis [SITB]). In 2022, reporting rates varied by facility type: 97% of community health centers, 85% of government hospitals, 82% of private hospitals, 21% of government clinics, and 22% of private clinics reported TB cases.

The SITB is an integrated online platform used to record and report all presumptive and confirmed TB cases, including drug-sensitive TB, drug-resistant TB, logistics, and laboratory data. The system is used in community health centers (Puskesmas) and other health facilities integrated with the SITB.

The TB case reporting process in the SITB begins with case detection (either passive or active), followed by data validation and registration of presumptive or confirmed patients in the system (identity and registration data). The process continues with the submission of laboratory tests, entry of laboratory results, and determination of the treatment regimen or treatment category. Finally, the system supports monitoring and reporting of treatment outcomes. A key feature of the SITB is the use of the National Identification Number as the primary identifier for data integration and patient tracking.

However, under-reported TB cases—defined as cases that are diagnosed and/or treated but not recorded in the SITB—remain a major challenge in Indonesia. The 2016–2017 TB Inventory Study (SIV-TB) estimated that 54% of childhood TB cases were not reported [10]. The 2023–2024 SIV-TB was conducted to further assess the magnitude of unreported TB cases. This article provides an overview of the under-reporting of TB cases among children younger than 15 years in Indonesia and examines factors associated with this issue.

METHODS

Study Design and Data Source

This study used a cross-sectional design and analyzed secondary data from the 2023–2024 SIV-TB in Indonesia, a national survey conducted by the Ministry of Health of the Republic of Indonesia. Data were collected from September 1, 2023 to November 30, 2023, using structured questionnaires completed by laboratory and non-laboratory facilities. The 2023–2024 SIV-TB was implemented in 31 districts and cities in Indonesia. These districts and cities were stratified into 3 regions: Sumatra, Java–Bali, and Eastern Indonesia (comprising Nusa Tenggara, Kalimantan, Sulawesi, Maluku, and Papua). This regional stratification reflects differences in TB incidence rates across Indonesia [11]. The target population of the SIV-TB consisted of all TB cases diagnosed and/or treated in government and private health care facilities in Indonesia.

The study sample included all TB cases in children younger than 15 years who were diagnosed or treated at government and private health facilities. Government facilities included hospitals owned by the Ministry of Health, provincial or local governments, state-owned enterprises, the military, the police, universities, or other ministries; community health centers; clinics (e.g., correctional institutions, detention centers, and port health offices); BBKPM/BKPM/BP4/community health halls; and independent laboratories. Private facilities included hospitals, clinics, independent practitioners, and laboratories.

All TB cases in children from eligible health facilities across 31 districts and cities were included. These facilities consisted of (1) laboratory facilities that performed TB diagnostic tests—such as smear microscopy, culture, serological tests, molecular rapid tests, or histopathology—within the 3 months preceding the study, and (2) non-laboratory facilities that diagnosed and/or provided anti-TB treatment during the same period. Pediatric TB cases were identified between September 1, 2023 and November 30, 2023, and included both bacteriologically confirmed and clinically diagnosed cases.

Samples were selected from the eligible population. The inclusion criteria consisted of children younger than 15 years who had been diagnosed with TB or were receiving TB treatment. Individuals who declined participation were excluded from the study. Prior to participation, informed consent was obtained from all participating government and private health facilities. For the present analysis, we focused on cases diagnosed within these health facilities.

Measurement of Variables

The dependent variable was under-reporting of TB among children younger than 15 years, defined as TB cases that were diagnosed and/or treated in health facilities but not reported to the SITB. Six independent variables were analyzed: age group, sex, health facility type, region, anatomical location of TB, and examination results. The determination of the dependent variable was based on data retrieved from the inventory study database. Age group was categorized into 3 groups: 0–4, 5–9, and 10–14 years. Sex was categorized as male or female. Health facility type was classified into 6 categories: community health centers, government hospitals, private hospitals, independent practitioners, clinics, and other facilities (including BBKPM/BKPM/BP4/community health halls). The region was categorized into 3 groups: Java–Bali, Sumatra, and Eastern Indonesia. TB anatomical location was classified as pulmonary or extrapulmonary. Examination results were categorized as bacteriologically confirmed or clinically diagnosed.

Statistical Analysis

Data were collected using questionnaires completed by laboratory and non-laboratory facilities. All responses were entered into a database, cleaned for accuracy, and standardized for variable names to facilitate proper linkage and merging. Survey weights were applied before analysis to account for the complex sampling design of the SIV-TB, including stratification by region and clustering at the district level. Because districts were selected with unequal probability—based on the estimated number of TB cases in each district—sampling weights were required in the analysis.

Duplicate records were removed using Stata version 14.2 (StataCorp, College Station, TX, USA) through two approaches: (1) deterministic matching based on exact matches for district/city, name, sex, date of birth, and national identification number; and (2) probabilistic matching using likelihood-based methods to identify records highly likely to be duplicates.

Record linkage was performed to compare SIV-TB data with deduplicated SITB data to identify unreported cases. Descriptive statistics were used to characterize pediatric TB cases. Under-reporting rates were estimated using complex survey analysis, accounting for sampling weights and stratification. Bivariate associations between independent variables and under-reporting were assessed using the chi-square test. Variables with a p-value <0.25 in the bivariate analysis, as well as those considered epidemiologically relevant based on prior evidence, were included in the multivariable model. Multivariable logistic regression was performed to identify factors independently associated with under-reporting of childhood TB while controlling for potential confounding variables. Multicollinearity among variables was assessed using variance inflation factors, with values >10 indicating significant multicollinearity.

Ethics Statement

All participating health facilities received detailed information about the study and provided written institutional consent through a form signed by the responsible official. Ethical approval for the study was obtained from the Health Research Ethics Committee of Jakarta II Health Polytechnic (LB 02.01/1/KE/L/777/2023). Individual patient consent was not required because the study involved no direct interaction with patients and used de-identified secondary data.

RESULTS

As shown in Figure 1, a total of 12 293 diagnosed childhood TB cases in children younger than 15 years were identified by participating health facilities between September 1, 2023 and November 30, 2023, across 31 districts and cities in Indonesia. Of these cases, 76.5% were reported to the SITB, whereas 23.5% remained unreported, indicating a substantial level of under-reporting. In this study, under-reporting was defined as TB cases that were diagnosed and/or treated within health facilities but were not reported to the SITB.

Table 1 shows the number and percentage of under-reported TB cases among children younger than 15 years, categorized by demographic characteristics, health facility type, region, anatomical location, and examination results. The highest under-reporting rate by age group was observed among children aged 5–9 years (24.7%). Regionally, Eastern Indonesia had the highest under-reporting rate (28.0%). The under-reporting rates were similar between boys (23.1%) and girls (24.0%). In terms of health facility type, government hospitals recorded the largest number of reported childhood TB cases (4421 cases). However, the highest under-reporting rates were observed among independent practitioners (95.9%), followed by clinics (74.2%).

In the bivariate analysis, the odds of under-reporting were 1.27 times higher among children aged 0–4 years (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.05 to 1.52; p=0.014) and 1.36 times higher among children aged 5–9 years (OR, 1.36; 95% CI, 1.12 to 1.65; p=0.003) than among children aged 10–14 years. No significant difference in under-reporting was observed by sex (OR, 1.03; 95% CI, 0.92 to 1.14; p=0.628). Pediatric TB cases in Eastern Indonesia were more likely to be unreported than those in Sumatra (OR, 1.49; 95% CI, 1.01 to 2.19; p=0.046). However, no significant association was observed for cases in the Java–Bali region (p=0.410). The largest differences were observed by health facility type. Compared with community health centers (Puskesmas), TB cases managed in private hospitals were 2.65 times more likely to be unreported (OR, 2.65; 95% CI, 1.76 to 4.00; p<0.001). The odds of under-reporting increased markedly in clinics (OR, 20.32; 95% CI, 6.70 to 62.14; p<0.001) and were highest among independent practitioners (OR, 221.39; 95% CI, 50.44 to 970.40; p<0.001). By contrast, the anatomical location of TB was not significantly associated with under-reporting. Extrapulmonary TB showed a higher likelihood of under-reporting than pulmonary TB, although this difference was not statistically significant (p=0.105). Likewise, no significant difference was observed between clinically diagnosed TB and bacteriologically confirmed TB (p=0.269).

The multivariable logistic regression analysis (Table 2) revealed that age group and health facility type were significantly associated with under-reporting after mutual adjustment. Specifically, children aged 5–9 years were 1.33 times more likely to be unreported than those aged 10–14 years (adjusted odds ratio [aOR], 1.33; 95% CI, 1.01 to 1.77; p=0.046).

Health facility type was also strongly associated with under-reporting. Compared with community health centers, private hospitals were 2.84 times more likely to under-report TB cases (aOR, 2.84; 95% CI, 1.91 to 4.24). Clinics were 20.72 times more likely to under-report (aOR, 20.72; 95% CI, 7.00 to 61.29), while independent practitioners were 224.39 times more likely to under-report (aOR, 224.39; 95% CI, 51.56 to 976.54). Other facilities were 3.54 times more likely to under-report TB cases (aOR, 3.54; 95% CI, 1.16 to 10.76) than community health centers.

DISCUSSION

Recording and reporting TB cases to the SITB, are critical to successful TB control in Indonesia. In this study, 12 293 childhood TB cases were identified from government hospitals, private hospitals, clinics, independent practitioners, BBKPM/BKPM/BP4/community health halls, and laboratories across 31 districts and cities in Indonesia. The under-reporting rate for childhood TB was 23.5%. In 2016–2017, the under-reporting rate of TB among children younger than 15 years was 54% [12]; this finding suggests a 31-percentage-point reduction in pediatric TB under-reporting over a 7-year period. The observed decrease may reflect strengthening of the TB surveillance system. Implementation of a more integrated digital reporting system, such as the SITB, likely improved the completeness and accuracy of pediatric TB case reporting. In addition, stronger policies and greater commitment to pediatric TB programs may have contributed to this improvement. Since 2016, pediatric TB has increasingly been prioritized within the national TB program through clearer diagnostic guidelines, defined case-finding targets, and integration of pediatric TB into routine program monitoring [13].

The 2023 SIV-TB found that TB cases among children younger than 15 years accounted for 19.8% of all TB cases across age groups. The increasing proportion of TB among children younger than 15 years may reflect ongoing household transmission, influenced by adult pulmonary TB, parental knowledge, and children’s BCG vaccination status [14]. Similarly, in the Philippines, children and adolescents aged 0–14 years represented 12.8% of new and relapsed TB cases in 2015 [15]. In China, cases among children aged 0–4 years accounted for approximately 64% of childhood TB cases [16]. In South Africa, the under-reporting rate of childhood TB was 12% among 443 children treated for TB. In Pakistan, by contrast, childhood TB under-reporting reached 78% [17]. Another study found that the under-reporting rate of childhood TB in hospitals providing directly observed treatment, short-course was 98% among 4821 cases [18]. Most childhood TB cases occurred among children aged 0–4 years (57%) and among boys (52%). However, another study estimated that the pediatric case detection rate was lower among children aged 0–4 years (41%; 95% CI, 34 to 50) than among those aged 5–14 years (63%; 95% CI, 53 to 75), with substantial variation across countries [19].

This study found an under-reporting rate of 23.5% for childhood TB. Under-reported TB cases have important implications for TB control programs because unreported cases may continue to contribute to transmission, particularly within households and communities. Moreover, children with TB whose cases are not reported are not captured in TB program monitoring systems, increasing the risk of incomplete treatment, treatment interruption, and treatment failure. Unstandardized and unsupervised treatment may also increase the risk of multidrug-resistant TB (MDR-TB). In addition, failure to report childhood TB cases hampers effective contact tracing.

The results showed that children aged 5–9 years were 1.33 times more likely to be unreported than those aged 10–14 years (aOR, 1.33; 95% CI, 1.01 to 1.77; p=0.046). TB cases in children aged 5–9 years may be at greater risk of under-reporting because of diagnostic challenges. Children in this age group often have difficulty producing sputum, making bacteriological tests such as Xpert MTB/RIF and acid-fast bacillus microscopy more difficult to perform. Consequently, TB diagnosis in this age group is often based on clinical judgment, including pediatric TB scoring systems. These clinically diagnosed cases may be less consistently recorded in surveillance systems than bacteriologically confirmed cases. In contrast, children aged 10–14 years are approaching adolescence and are generally better able to produce sputum, which facilitates bacteriological testing and may increase the likelihood of reporting to the TB information system [16].

Another study by Lestari et al. [20] found that children aged 0–4 years were at greater risk of under-reporting. Similarly, a study in China reported that pediatric patients younger than 15 years had significantly higher odds of under-reporting (aOR, 7.3; 95% CI, 3.6 to 14.9) than those older than 15 years [21]. Regarding health care utilization, most childhood TB cases were diagnosed in government hospitals, private hospitals, and community health centers rather than in clinics, independent practitioners’ offices, or other facilities such as BKPM, BP4, community health halls, or laboratories. As observed in China, many TB diagnoses made in hospitals were not captured in the national TB registry due to the absence of a reporting system [21].

Under-reported cases represent unidentified sources of active transmission, thereby potentially perpetuating transmission within households and communities. In addition, children with TB who are not incorporated into the TB program monitoring system may be at increased risk of incomplete treatment, treatment interruption, and treatment failure. Unstandardized and unsupervised treatment may further increase the risk of MDR-TB. Moreover, failure to report childhood TB cases hampers contact tracing, allowing active TB among family members to remain undetected and perpetuating the cycle of TB transmission.

The study also revealed that 27% of 3699 childhood TB cases diagnosed in private hospitals and 16% of 4421 cases diagnosed in government hospitals were not reported to the SITB. These findings suggest that the likelihood of under-reporting is strongly influenced by health facility type, with private-sector facilities displaying particularly large reporting gaps.

Independent practitioners were 224.39 times more likely to under-report TB cases than community health centers (aOR, 224.39; 95% CI, 51.56 to 976.54). This finding should be interpreted cautiously. The sample size from independent practitioner facilities was relatively small, limiting the statistical power and the generalizability of the estimate for this facility type. Although the proportion of unreported pediatric TB cases was high in these facilities, the absolute number of pediatric TB cases managed there was substantially lower than that in community health centers, government hospitals, and private hospitals. Consequently, the overall contribution of independent practitioner facilities to national pediatric TB under-reporting may be limited.

Clinics were 20.72 times more likely to under-report TB cases than community health centers (aOR, 20.72; 95% CI, 7.00 to 61.29). Other health care facilities, such as BKPM, BP4, community health halls, and laboratories, were 3.54 times more likely not to report childhood TB cases to the SITB than community health centers (aOR, 3.54; 95% CI, 1.16 to 10.76). Private hospitals were 2.84 times more likely to under-report TB cases than community health centers (aOR, 2.84; 95% CI, 1.91 to 4.24).

Finally, the high level of under-reporting of childhood TB among independent practitioners and private clinics appears to be associated with systemic weaknesses [22]. Under-reporting of childhood TB cases, especially from private health facilities such as independent practitioners and private clinics, hinders national TB elimination efforts. Several health facilities, especially clinics and independent practitioners’ offices, lack internal standard operating procedures for data collection and mandatory reporting through the SITB [23]. In addition, limited awareness of reporting obligations among independent physicians contributes to the under-reporting of childhood TB [24]. One study also reported that patients with TB diagnosed by physicians with higher levels of competence have lower under-reporting rates than those managed by less competent physicians [25].

The high under-reporting rate of childhood TB in clinics and independent practitioners’ offices may be partly attributable to a greater focus on curative services, with less emphasis on administrative reporting requirements for public health programs [26]. This issue may be compounded by limited human resources assigned specifically to reporting tasks and by restricted access to online reporting systems.

Under-reporting of childhood TB cases may leave sources of active transmission unidentified. In addition, failure to incorporate affected children into TB program monitoring systems increases the risk of incomplete treatment, treatment discontinuation, and treatment failure, which may contribute to the development of drug-resistant TB. Under-reporting of childhood TB cases, especially from private health facilities such as independent practitioners and private clinics, may hinder national TB elimination efforts. Strengthening active case finding and targeted contact tracing may improve reporting of childhood TB cases [27]. Implementation of national regulations, such as Presidential Regulation No. 67 of 2021 [28], along with public-private partnerships and incentives for private health care providers, could further enhance compliance with TB notification protocols [29].

Recording and reporting TB cases through the SITB also have several limitations, particularly those related to data integration across health facilities, limited human resources, and infrastructure constraints. The absence of dedicated medical records officers or nurses specifically assigned to TB reporting, the burden of multiple responsibilities, and frequent staff turnover associated with contract-based employment can contribute to suboptimal reporting processes. In addition, some health care personnel perceive the SITB as complex and difficult to use.

This study has several limitations. The sample sizes from independent practitioner facilities, clinics, and other facilities were limited. Although the proportion of under-reported pediatric TB cases was relatively high in these facilities, the number of patients with TB treated there was smaller than that in community health centers, government hospitals, and private hospitals. In addition, TB diagnosis was based on self-report and may therefore have been subject to recall bias. Diagnoses were based on respondents’ reports that they had been examined by medical personnel.

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Acknowledgements

None.

Author Contributions

Conceptualization: Tobing KL, Lolong DB, Suriani O, Yusniar, Aryati R, Farid MN. Data curation: Tobing KL, Lolong DB, Suriani O, Yusniar, Aryati R, Farid MN. Formal analysis: Tobing KL, Lolong DB, Suriani O, Yusniar. Funding acquisition: None. Methodology: Lolong DB, Farid MN. Project administration: Suriani O, Yusniar, Aryati R. Visualization: Tobing KL. Writing – original draft: Tobing KL, Lolong DB, Lasut D, Widiyanti M, Senewe FP, Soerachman R, Suriani O, Yusniar, Aryati R, Farid MN. Writing – review & editing: Tobing KL, Lolong DB, Lasut D, Widiyanti M, Senewe FP, Soerachman R, Suriani O, Yusniar, Aryati R, Farid MN.

Figure 1

Flowchart of childhood tuberculosis (TB) under-reporting. SITB, National TB Surveillance System (Sistem Informasi Tuberkulosis).

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