Alifaturrasyid

Indonesia
12-September
-2019

SCIENTIFIC ESSAY COMPETITION MEDICAL FIESTA 2019

The Implementation of Congenital Hypothyroidism Screning National Programme:
Expanding the Coverage and Improving the Quality

INTRODUCTION

The This is cCongenital hypothyroidism (CH) is a state of thyroid hormone

deficiency which present in a newborn.1 Thyroid hormone is an important component for
maturation and growth in various tissues and organs, including bone and brain, in which its
deficiency could lead to severe mental retardation and other complications if the case is left
undetected and untreated.2 HypothiroidismHypothyroidism resulted in growth, motoric, and
intellectual development abnormality. The incidence of congenital hypothyroidism varies in
different geographic location around the world. Globally, The annual incidence of congenital
hypothyroidism is around 1:3000 -1:4000).3 A retrospective study in France which
summarized data of newborn screening for 20 years reported that the annual incidence of CH
is 1:10.000(4). The available data of Indonesian newborn population from the Cipto
Mangunkusumo Hospital (RSCM) and Hasan Sadikin Hospital found 1: 2513 ratio which is
higher than the estimated global ratio. of 1: 3000 births.

The clinical manifestation of CHS in newborns is atypical since there are presences
of residual thyroid hormone from mothers during their pregnancy.2 Regarding it, the
detection and diagnosis of CH have to be done through the screening.2 The diagnosis of
newborn with congenital hypothyroidism somewhere in the absence of screening program
will most likely too late to be known and maybe suspected in the later age when the disease
already symptomatic.2 That is why the screening program for congenital hypothyroidism is
very important for the early detection and hence prompt treatment to prevent long-term
complications can be deployed.2,3 Although screening program has one goal, it is
implemented differently in several countries. The difference in method and strategy could
possibly be the reason why incidence of congenital hypothyroidism differs in each country.

The congenital hypothyroidism-screening program (CHSP) has been implemented in

Indonesia as a national program. The program is expected to be implemented in all 34
provinces in Indonesia by 2019. However, there are several problems underlying the
implementation of it.2 So far, congenital hypothyroidism screening program has only been
implemented in 11 provinces.2 It happens due to the limited resources, especially as in the
workforces, laboratory facilities, and other logistics, which is only available in certain
healthcare facilities.2 Some private hospitals do not have the facilities and other necessities
to do such screening program.2 Moreover, not all newborns in Indonesia were delivered in

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hospitals or other formal healthcare facilities.2 Instead, some mothers gave birth in other
informal non-institutional services due to their lack of financial capacity and having their
own beliefs, especially those who live in rural areas and have a low socioeconomic status.
The increase in the quality and scope of congenital hypothyroidism screening program in
Indonesia is vital so that all newborns, even in urban area, will receive thyroid screening to
decrease the incidence and prevalence of the disease. In this essay, possible measures and
solutions to solve the current problems underlying CHS implementation will be addressed.

BODY

Congenital hypothyroidism (CH) is a disorder in children due to the lack of thyroid

hormone that occurs since a child is still in the womb. Infants with CH abnormalities will
experience growth and mental retardation. CH conditions and their effects can be either
temporary or permanent for life. Even if the hypothyroid condition is temporary, the impact
on a child's life is likely to last throughout his/her life. This could happen because the
condition of hypothyroidism could affect the child's brain development.
In Indonesia, a study that examine TSH found the estimated prevalence of
hypothyroidism in the general population is 2.7% in men and 2.2% in women. While in the
population of individuals aged >15 years, the prevalence of hypothyroidism was 0.4% or
around 700,000 individuals throughout Indonesia in 2013. Available data are from the RSCM
(RSUPN Dr. Cipto Mangunkusumo) or Dr. Cipto Mangunkusumo Public Hospital) and
Hasan Sadikin Hospital in Bandung, in which screening results for 2013,669 infants show
positive results in 85 infants. Thus, the ratio of congenital hypothyroidism cases is 1: 2513.
This figure is higher than the estimated global ratio of 1: 3000 births. The estimation of
congenital hypothyroidism occurrence in Indonesia is that if there are 5 million births / year,
with an incidence ratio of 1: 3000, there will be more than 1600 babies with congenital
hypothyroidism in Indonesia per year.5
These data indicate that congenital hypothyroidism is a prevalent disorder in
Indonesia.both CH causes permanent decline in the quality of a person's life due to obstacles
to children's growth and development, especially impaired cognitive function and mental
retardation. Besides, CH is usually asymptomatic in its early phase and becomes
symptomatic when it is’s already severe. If not treated immediately, the impact will affect
the health of the community and the country as a whole. Appropriate medical treatment can
be done to prevent and cure the child to normal conditions and development thus making
early detection essential.
Congenital hypothyroidism screening in newborns is a national program that has been
established by the government through the Minister of Health Regulation number 78 year
2014. This screening is carried out for infants between 48 and 72 hours after birth. Every
health facility that conducts screening is required to carry out recording and reporting data,
which will be recapitulated in stages to the central national level.2
This program has already implemented in 11 provinces in Indonesia in 2013 and is
targeted to be implemented in all provinces in Indonesia by the end of 2019. The scope of
this program will be extended to other provinces by taking into account the regional enclaves
with iodine deficiency and minimal availability of resources.
The government’s target to implement the program had numerous challenges to
overcome and issues to be addressed. The data from Yogyakarta province showed that the
number of primary and secondary health facilities that implement this program in 2015 are
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only 5.8% and 15.1%, respectively. Besides, the coverage of this program was still relatively
low in which the percentage of babies screened with respect to total number of babies born
in three respective years of 2013, 2014, and 2015 were only 10.8%, 10.0% and 10.3%.1 The
execution timing of the screening is also a problem, which is either too early or too late.2
Another report from a primary healthcare facility in Lampung province has identified
systematically the problems encountered along the CHSP implementation from several
aspects. Lack of facilities or equipment to conduct the screening and the absence of standard
operating procedure (SOP) for the implementation is currently a problem in the input aspect.
Ineffectiveness of socialization and education for the society due to the lack of interest and
participation is also found as a process problem. From the output aspect, the problem is low
coverage in which only 35 out of 141 new-borns were screened in 2017. In the other region,
East Oku regency, the CHSP has not been implemented in the primary care settings until
2018 due to the absence of regional government law basis.3
From the various problems encountered during the planning or the implementation of
CHSP program, it is clear that there are abundant issues to be solved to increase the coverage
of the program as well as its quality. The first thing to do is to adapt the minister of health
decree to province and regional regulation hence the legal basis is available to allocate funds,
health professional, and the other required resources. Government support both from legal
aspects as well as from resources supply is fundamental for the initial implementation as well
as for the expansion of program’s coverage. Governmental support alone might be inadequate
to make this problem implemented in national scope. The private sector as well as support
from the society will be certainly required. A public – private mix scheme could be a
promising alternative in which private sector provides the supply and perform the distribution
of the instruments. Meanwhile, governmental institution of health sector focus on the
planning, resource allocation, program execution, reporting and evaluation. Participation
from the society is equally important to make the program familiar and people are encouraged
to participate. The dissemination of information about the availability of this program in the
primary care service must be known well by the society hence the utilization of any social
media available including television, radio, newspaper, public billboard, and smartphone-
based social media for this purpose will be beneficial. Lastly, proper monitoring, reporting,
and evaluation of this program is highly important to ensure the continuity of this program.

CONCLUSION

Congenital hypothyroidism is a serious problem of a neonate, which can be

disastrous, as it will cause mental retardation and many other serious health problem in one’s
later life and in a broader scale will significantly reduce both individual life and national
human resource quality. The newborn hypothyroid screening is the most effective means of
finding as many cases as possible and as fast as possible hence proper medical treatment can
be given to enable proper growth and development of the children and prevent them from
mental retardation and many other diseases. There are various issues regarding the current
implementation of the screening program and there are various opportunities for the
improvement of the program for the sake of increasing the coverage of the screening.

WORKS CITED

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REPUBLIK INDONESIA NOMOR 78 TAHUN 2014 TENTANG SKRINNING
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