Environmental Quality Factors with The Incidence of Pulmonary Tuberculosis: A Literature Review
Hanung Nurany1*, Mursid Raharjo2, Mateus Sakundarno Adi3
1,2,3Departemen of Environmental Health, Faculty of Public Health, Diponegoro University, Semarang, Indonesia
Jl. Prof. H. Soedarto, S.H.,Tembalang, Semarang, Indonesia 50275
*Koresponden email: [email protected]
Received: May 6, 2022 Accepted: May 28, 2022
Abstract
Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis that can attack the lungs and other organs. Tuberculosis (TB) is still a global priority health problem because Indonesia is one of the countries with the highest number of TB cases in the world. It is estimated that around 845.000 Indonesians in 2019 suffer from tuberculosis. Around 92,700 people die from TB in Indonesia per year. The purpose of this study was to determine the environmental risk factors with the incidence of pulmonary tuberculosis (TB). The method in this study uses the literature review method by selecting data sources according to the desired topic and criteria. The data base used in the search for sources is Google Scholar, ejournal.undip.ac.id, and Portal Garuda, with the keywords pulmonary tuberculosis, TB incidence factors, tuberculosis environmental factors, and the physical condition of the TB patient's house. The results of studies from 10 scientific journals on environmental risk factors for TB disease show that ventilation area, occupancy density, lighting intensity, humidity and room temperature are risk factors for TB incidence.
Keywords: tuberculosis, environmental risk factors, ventilation area, occupancy density, lighting intensity, humidity, room temperature
Abstrak
Tuberkulosis (TB) adalah penyakit menular yang disebabkan oleh Mycobacterium tuberculosis yang dapat menyerang paru-paru dan organ tubuh lainnya. Tuberkulosis (TB) masih menjadi masalah kesehatan prioritas global karena Indonesia merupakan salah satu negara dengan jumlah kasus TB tertinggi di dunia.
Diperkirakan sekitar 845.000 penduduk Indonesia pada tahun 2019 menderita tuberkulosis. Sekitar 92.700 orang meninggal akibat TB di Indonesia per tahun. Tujuan penelitian ini adalah untuk mengetahui faktor risiko lingkungan dengan kejadian tuberkulosis paru (TB). Metode dalam penelitian ini menggunakan metode literatur review dengan memilih sumber data sesuai dengan topik dan kriteria yang diinginkan.
Basis data yang digunakan dalam pencarian sumber adalah Google Scholar, ejournal.undip.ac.id, dan Portal Garuda, dengan kata kunci TB paru, faktor kejadian TB, faktor lingkungan TB, dan kondisi fisik rumah pasien TB. Hasil penelitian dari 10 jurnal ilmiah tentang faktor risiko lingkungan penyakit TB menunjukkan bahwa luas ventilasi, kepadatan hunian, intensitas pencahayaan, kelembaban dan suhu ruangan merupakan faktor risiko kejadian TB.
Kata Kunci: tuberkulosis, faktor risiko lingkungan, luas ventilasi, kepadatan hunian, intensitas pencahayaan, kelembaban, suhu ruangan
1. Introduction
Tuberculosis is an infectious disease that is a major health problem and one of the main causes of death in the world. About a quarter of the world's population is infected with Mycobacterium tuberculosis.
According to the World Health Organization (WHO), Indonesia is included in the list of 30 countries with the highest burden of Tuberculosis (TB) in the world and ranks third in the world regarding the incidence of TB. The World Health Organization (WHO) estimates that in 2019 around 845,000 suffer from TB and around 92,700 people die from TB every year [1].
Tuberculosis is a disease of the urinary tract breath caused by mycobacterium, which breeds in the part of the body where there is lots of blood and oxygen[2]. This disease caused by bacteria and is transmitted through the air (airborne diseases) and can survive in the air. Infection These bacteria usually spread through the blood vessels and lymph nodes clear, but mainly attacking lungs [2]. Bacteria in dry sputum attached to dust are able to survive longer, namely for 8-10 days [3]. Environmental-based disease is a pathological condition in the form of functional or morphological abnormalities of an organ caused by human interaction with everything around that has the potential to cause disease [4]. Several environmental
risk factors for TB disease are temperature, residential density, house humidity, ventilation, and lighting [5]. Crowded living conditions, slums, poor air circulation and insufficient sunlight are triggers for the bacteria that cause tuberculosis to live long, this is because the room is dark, damp, cold, and does not have good ventilation. Therefore, the construction of residential houses that meet health requirements must always be considered so that every room in the house gets a clean change of air flow and gets sufficient sunlight so that the risk of disease caused by poor air quality can be reduced[6].
According to the theory of John Gordon [7] the emergence of a disease is based on 3 very influential aspects, namely the host (host), agent (disease), environment (environment). These three factors are called the epidemiological triangle. These three aspects must be balanced, if there is an imbalance then a person can become sick. Therefore, prevention is necessary[7]. Prevention of environmental-based diseases that are transmitted through the air can be done by knowing the environmental risk factors that influence so that these risk factors can be controlled to reduce the potential for transmission and spread of disease, so that the degree of health can be improved. Based on the description above, the researcher wants to know more about the environmental risk factors that can affect the transmission and spread of TB cases that occur[8].
2. Material and Methods
The method used in this study is to use a literature review. The data sources used are scientific publication journals using the keywords pulmonary tuberculosis, TB incidence factors, tuberculosis environmental factors, and the physical condition of TB sufferers' homes, which were accessed in March- April 2022 with a journal publication range from 2015-2022. The databases used in the source search are Google Scholar, ejournal.undip.ac.id, and the Garuda portal. The inclusion criteria in the disbursement of scientific publications are journals that are published and can be accessed in full text in accordance with the research objectives and relevant materials.
3. Results and Discussion
Table 1 shows the articles found by author name, method, variables, and results which will be discussed further in this paper. There are 10 articles related to environmental quality factors with the incidence of Pulmonary Tuberculosis.
Table 1. Article results
No. Authors Methods Variables Results
1. Agustina Ayu Wulandari, Nurjazuli, M.
Sakundarno Adi/2015
Case Control and Cross Sectional
Risk factors for the physical environment of the house
(ventilation area, occupancy density, intensity of natural lighting, humidity, room temperature)
The results of the bivariate analysis showed that the risk factors for the physical home environment were associated with the incidence of pulmonary tuberculosis with a significance value/CI (p-value) <
0.05 respectively.
- Ventilation area (p- value=<0.001)
- Occupancy density (p- value=0.001)
- Natural lighting intensity (p- value=0.006)
- Room humidity (p-
value=<0.012)
- Room temperature (p- value=<0.001).
2. Gita Sekar Prihanti, Sulistiyawati, Ina
Rahmawati/201 5
Case Control Occurrence risk factors (ventilation, overcrowding)
The results of the binary logistic regression test showed that there was a significant effect on the incidence of pulmonary TB with (p- value) < 0.05 respectively:
- Ventilation (p-value = 0.000;
OR = 0.041; CI = 0.001-1.432) - Occupancy density (p-value =
0.000; OR = 0.113; CI 0.001- 1.301)
No. Authors Methods Variables Results 3. Evin
Kenedyanti, Lilis
Sulistyorini/20 17
Case Control Physical condition of the house (ventilation, temperature,
humidity, occupancy density, lighting)
The results of the univariate analysis show that:
- TMS ventilation: 5 respondents with TB (100%), 7 respondents without TB (70%)
- TMS occupancy density: 5 respondents with pulmonary TB (100%), 5 respondents with non-TB patients (50%)
- TMS lighting: 4 respondents with pulmonary TB (80%), 8 respondents not with pulmonary TB (80%) (Not a TB risk factor)
- TMS humidity: 4 respondents with pulmonary TB (80%), 4 respondents without pulmonary TB (40%)
- TMS temperature: 1 respondent with pulmonary TB (20%), 4 respondents not with pulmonary TB (40%).
Temperature is not a risk factor.
4. Siti Thomas Zulaikhah, Ratnawati, Neng Sulastri, Eli
Nurkhikmah, Novi Dian Lestari/2019
Case Control Home environmental factors (ventilation area, occupancy density, humidity, lighting, and temperature)
The results of the bivariate analysis showed that:
- Ventilation area (p-value = 0.000; OR = 5.57; 95% CI = 2.12-14.65).
- Occupancy density (p- value=0.000; OR=6.67;
95%CI=2.44-18.21).
- Exposure (p-value=0.001;
OR=4.89; 95% CI=1.89 - 12.67).
- Humidity (p-value=0.001;
OR=5.17; 95%CI=1.95-13.70).
- Temperature (p-value=0.001;
OR=4.66; 95%CI=1.76-12.31).
5. Mudiyono, Nur Endah W, M.
Sakundarno Adi/2017
Case Control Physical condition of the house (ventilation area, occupancy density, natural lighting, humidity, and temperature)
The results of bivariate analysis with (p-value) < 0.05 respectively are as follows
- Ventilation area (p-value = 0.004; OR = 3.662; 95% CI = 1.559-8.418),
- Occupancy density (p- value=0.001; OR:6,641, 95%
CI: 2,769-15,927)
- Natural lighting (p-value=
0.016; OR = 2.912; 95% CI = 1.290-6.571).
- Humidity (p-value = 0.001; OR
= 6,000; 95% CI = 2.528- 14.240)
- Room temperature (p-value = 0.036; OR = 2.298; 95% CI = 1.148-6.341)
6. Nike Monintja, Finny Warouw,
Odi Roni
Pinontoan/2020
Cross Sectional
Physical condition of the house (natural lighting and ventilation area)
The results of the analysis are as follows:
- Ventilation area: Chi-square test results obtained p value =
No. Authors Methods Variables Results
0.001 (p < 0.05). Then there is a relationship between ventilation area and pulmonary tuberculosis, with OR 3.354 and 95% CI = 1.037-10.853 - Exposure p-value=0.000(p <
0.05). There is a relationship between natural lighting and pulmonary tuberculosis with an OR value of 4.808 and 95% CI
= 0.832-27.798.
7. Kusrianti, Asbath Said/2019
Case Control Risk factors (occupancy density and ventilation)
The results showed that the OR value:
- Ventilation OR=0.661<1 (not a risk factor)
- Occupancy density
OR=2,455> 1 (a risk factor) 8. Farrah
Fahdhienie, Agustina, Phossy Vionica Ramadhana/20 20
Case Control Risk factors for TB incidence (humidity and occupancy density)
The results showed that:
- Occupancy density has no relationship.
- Humidity (p-value = 0.015; OR
= 4.25; 95% CI = 1.33-13.56).
9. Jamal Buton, Leniarti Ali/2018
Case Control TB risk factors (occupancy density)
OR value research results:
- Occupancy density OR=0.864
< 1, there is no relationship with occupancy density 10. Surakhmi
Oktavia, Rini Mutahar, Suci Destriatania/20 16
Case Control Risk factors for TB incidence (ventilation area and occupancy density)
The results showed that:
- Ventilation area (p-value = 0.001; OR = 27.12; 95% CI 5.49-133.84)
- Occupancy density (p-value=
0.02; OR=4.3; 95% CI 1.39- 12.95)
Source: Data processing (2022) Occupancy Density
Occupancy density is the floor area in the house divided by the number of family members of the occupant. Density of residents in one house will have an effect on its inhabitants. The area of the house that is not proportional to the number of residents will make it overcrowded[9]. Excessive occupancy density creates unhealthy conditions besides that it can cause a lack of oxygen consumption, and if one of the family members is infected with pulmonary TB, the density of the occupancy will be a risk factor for transmission.
Occupancy density is categorized as eligible if per 8 m² is filled by no more than 2 people except children under 5 years old[10].
From the results of a literature review of 10 journals discussing occupancy density as a TB risk factor, 9 journals and 7 journals stated that occupancy density had a significant relationship with TB incidence and 2 other journals stated that occupancy density had no relationship with TB incidence.
The results of 7 journals show that statistically the research results are as follows (p- value=0.001;95%CI)[11]; (p-value = 0.000; OR = 0.113; CI 0.001-1.301)[9]; (p-value=0.000; OR=6.67;
95%CI=2.44-18.21)[12]; (p-value=0.001; OR:6,641, 95% CI: 2,769-15,927)[13]; (OR=2.455> 1)[14]; (p- value= 0.02; OR=4.3; 95% CI 1.39-12.95);[15] and one journal discussing univariately showed that 5 respondents with pulmonary TB (100%) had a residential density that did not meet the requirements, 5 respondents who did not have TB (50%) had a residential density that did not meet the requirements[3].
From the results of this study, it is known that someone who lives in a residential density that does not meet the requirements can have a risk of 0.1 - 6.67 times compared to someone who lives in a residential density that meets the requirements.
Occupancy density can be a risk factor for TB transmission because it is related to the quality of air exchange in the house. In addition, the denser the number of occupants in one room, the higher the humidity
caused by human sweat and when humans breathe out water vapor[3]. In a closed room with many occupants, the humidity will be higher than outdoors or in a less crowded room.
Humidity has a role for the growth of microorganisms including tuberculosis (TB) bacteria. The dense population also allows for more frequent contact between people with pulmonary TB and family members, thereby accelerating the transmission of the disease. To reduce the risk factor for residential density, it can be done by maximizing the air circulation in the house such as windows and doors that are often opened or by adjusting the density of occupants in existing rooms.
Meanwhile, from the results of the literature review, there are 2 journals which state that occupancy density is not related to the incidence of TB. The OR value of occupancy density (OR = 0.864 < 1), which means that there is no relationship between the incidence of TB and occupancy density of[16], and according to research[17], occupancy density has no relationship, but the p-value is not stated because the research data are homogeneous, that is, there are only one category of all respondents' answers. However, residential density remains a risk factor for TB incidence and is highly dependent on the quality of the building and the existing ventilation area.
Humidity
Humidity is the total content of water vapor in the air which can be measured using a thermohygrometer in units (%). The humidity in the room that is considered ideal and meets the requirements ranges from 40-60%[18]. Moisture is one of the factors in the growth of bacteria and viruses.
Based on the results of a literature review of 5 journals which stated that humidity was a risk factor and was associated with the incidence of TB. The results of the study were successively with a degree of significance (p-value) < 0.05. Statistical results of room humidity value (p-value = 0.012)[11]; (p- value=0.001; OR=5.17; 95% CI=1.95-13.70)[12]; Humidity (p-value=0.001; OR=6,000; 95% CI=2.528- 14.240)[13]; (p-value = 0.015; OR = 4.25; 95% CI = 1.33-13.56)[17] and one journal with univariate analysis showed that 4 respondents with pulmonary TB (80%) had humidity that did not meet the requirements and 4 control respondents (40%) do not have the humidity that meets the requirements. The results of these studies show that someone who lives in humidity that does not meet the requirements can have a risk of developing pulmonary TB by 4.25 - 6 times more risk than someone who lives in humidity that meets the requirements.
Theoretically, high humidity can cause clusters of particles in the air and larger particles are believed to cause infection compared to small particles. High humidity conditions can cause dry mucosa and will reduce the ability to fight microorganisms that enter the respiratory tract[5]. Air humidity that is too high or too low can be a breeding ground for microorganisms, including Mycobacterium tuberculosis[18]. The cause of high air humidity at home/residential can be caused by several factors including the construction of the roof of the house that leaks, the floor of the house and the walls of the house that are not waterproof so that water can seep through the pores of the construction[12].
If the air humidity is less than 40%, the air sanitation efforts that can be done include: a) using a humidifier that can increase the humidity, b) opening the windows of the house, c) expanding the windows of the house, d) modifying the physical building (increasing lighting and air circulation). If the humidity is more than 60%, efforts that can be made include: a) Installing glass tiles and b) Using tools to reduce humidity such as a dehumidifier.
Ventilation Area
Ventilation is a place for air to enter and leave as well as an external lighting hole, which functions to keep the air flowing fresh[5]. House ventilation that meets the requirements according to regulations is a permanent ventilation area of 10% of the floor area[10]. Ventilation area that does not meet the requirements (< 10% of the floor area) can result in reduced oxygen concentration and increased carbon dioxide concentration which is toxic to the occupants, in addition to ventilation that does not meet the requirements can cause an increase in room humidity caused by obstruction of the air exchange process and sunlight that enters the house, as a result mycobacterium tuberculosis bacteria released by TB patients when coughing and sneezing can survive in the room and are inhaled through the respiratory process.
Based on 10 journals conducted by a literature review, there are 8 journals that discuss that ventilation area is an environmental risk factor for TB incidence. Seven (7) journals stated that the ventilation area had a significant relationship with the incidence of TB, with the results of the following consecutive studies as follows: ventilation area statistics (p-value=<0.001)[11]; (p-value = 0.000; OR = 0.041; CI = 0.001- 1.432)[9]; (p-value=0.000; OR=5.57; 95% CI=2.12-14.65)[12]; (p-value=0.004; OR=3.662; 95% CI = 1.559-8.418)[13]; (p-value=0.001; OR=3.354; 95% CI =1.037-10.853)[19]; (p-value = 0.001; OR = 27.12;
95% CI 5.49-133.84)[15], one journal discussed univariately that out of 5 respondents with TB (100%) had ventilation areas that did not meet the requirements and 7 control respondents (70%) had TMS[3]. The
ventilation area has a significant relationship because it causes air circulation to be not smooth and reduces the natural light that enters. Based on these studies, a person who lives with a ventilation area that does not meet the requirements can have a risk of 0.041 – 27.12 times the incidence of TB. Mycobacterium tuberculosis bacteria roam in rooms that do not have good air circulation/ventilation.
Meanwhile there is 1 journal which states that ventilation area does not have a significant relationship with the incidence of TB, the results show that ventilation has an OR = 0.661 < 1 with a Lower Limit value (0.186) and Upper Limit (2.355)[14] which means it is not a risk factor. occurrence of TB.
Temperature
Temperature is a measure of the heat of an object, while air temperature is a measure of the hotness and coldness of the earth's surface and atmosphere. Air temperature is expressed in units of Celsius, Fahrenheit, Reamur, or Kelvin which is measured using a temperature measuring device called a thermometer. Temperature is invisible but can be felt the high and low temperature. Temperature is one of the factors for the proliferation of TB bacteria in the air. If a person with pulmonary TB coughs or sneezes, it can produce about 3000 phlegm droplets. Sputum sprinkling containing tuberculosis bacteria can survive in the air at room temperature for several hours[11]. The temperature range favored by Mycobacterium tuberculosis is 25 ̊C – 40 ̊C and the bacteria will grow optimally at a temperature of 31 ̊C – 47 ̊C [3]. House air temperatures are considered eligible if 18 ̊C -31 ̊C[18].
Based on the results of a literature review of 10 journals that discuss environmental risk factors for TB, there are 4 journals that discuss temperature as an environmental risk factor for TB disease. There are 3 journals which state that it has a significant relationship with the incidence of TB. The results of the study respectively with the degree of significance (p-value) < 0.005 as follows (p-value = <0.001)[11]; (p- value=0.001; OR=4.66; 95%CI=1.76-12.31)[12]; (p-value=0.036; OR=2,298;95% CI=1,148- 6,341)[13].
The results of this study indicate that the quality of air temperature that does not meet the requirements can have a risk of 2.298 - 4.66 times the occurrence of TB as seen from the Odds Ratio (OR).
Meanwhile, there is 1 journal which states that temperature does not have a significant relationship with the incidence of TB. From the results of research 2 stated that there was 1 respondent (20%) with TB who had a temperature that did not meet the requirements and 4 respondents (40%) control did not have a temperature that met the requirements. Although in this study temperature did not have a significant relationship, room air temperature was a risk factor for TB. According to the researchers, the temperature results are greatly influenced by weather conditions at the time of measurement[3].
Lighting
Lighting is something that gives light (rays) or that illuminates, lighting includes natural lighting and artificial lighting. Natural lighting is a source of lighting that comes from sunlight while artificial lighting is lighting that is produced by light other than sunlight[20]. The ideal lighting value (lux) in the house is at least 60 lux[18]. Too high lighting can increase the room temperature while lighting too low can increase eye accommodation. Lighting in the space of the house is endeavored to meet the need to see around.
Natural and artificial lighting will be a risk factor for TB disease when there is insufficient light because it can increase the humidity in a higher room, so that it can affect the growth of TB bacterial microorganisms.
Based on the results of a literature review of 10 journals, there are 5 journals that discuss lighting with the incidence of TB. There are 4 journals which state that lighting has a significant relationship with the incidence of TB. The results showed (p-value = 0.006)[11]; (p-value=0.001; OR=4.89; 95% CI=1.89 - 12.67)[12]; (p-value= 0.016; OR = 2.912; 95% CI = 1.290-6.571)[13], (p-value=0.000; OR 4.808 and 95%
CI = 0.832-27.798)[19]. Based on the results of these studies, someone who lives in lighting that does not meet the requirements has a probability of 2,921-4.89 times the occurrence of TB compared to someone who lives in a place of residence with lighting that meets the requirements. Light has properties that can kill bacteria, especially natural light that contains UV rays. Lighting can be obtained by adjusting artificial light and natural light from sunlight. Natural lighting is obtained from sunlight entering through ventilation or windows or from glass tiles.
Lack of or low sunlight entering the house tends to make the air more humid and the room darker so that bacteria can survive for days or even months[3]. Insufficient lighting can be caused by several factors including lack of ventilation in the house, not opening existing windows, sunlight being blocked by the walls of neighboring houses due to dense settlements.
However, from the results of the literature review there is 1 journal which states that lighting is not a risk factor for TB, this is because the results of the univariate analysis showed that 4 respondents with pulmonary TB (80%) had lighting quality that did not meet the requirements, 8 respondents were not patients with TB. lungs (80%) also have lighting quality that does not meet the requirements this is because in this study the lighting requirements were not fulfilled due to the behavior and condition of the
respondent's house which tended to be the same both in TB patients and non-TB patients, namely rarely opening windows and existing windows. blocked by other building walls[3].
4. Conclusion
Based on the results of a search of 10 journals on environmental risk factors for tuberculosis, the following conclusions can be drawn: (a) TB is an environmental-based disease; (b) Environmental risk factors for TB disease include ventilation area, occupancy density, lighting intensity, room humidity and room temperature; (c) each of these environmental risk factors is influenced by their respective environmental conditions. (d) Environmental risk factors for the occurrence of TB that do not meet the requirements can lead to a greater risk of TB incidence. (e) Environmental risk factors for TB incidence can be controlled to reduce the spread and transmission of TB disease.
6. References
[1] Kementerian Kesehatan RI, Petunjuk Teknis Pendampingan Pasien TBC Resistan Obat Oleh Komunitas. 2011.
[2] S. Rahayu and M. A. Sodik, “Pengaruh Lingkungan Fisik Terhadap Kejadian Tb Paru,” Encephale, vol. 53, no. 1, pp. 59–65, 2018.
[3] E. Kenedyanti and L. Sulistyorini, “Analisis Mycobacterium Tuberkulosis dan Kondisi Fisik Rumah dengan Kejadian Tuberkulosis Paru,” J. Berk. Epidemiol., vol. 5, no. 2, pp. 152–162, 2017, doi:
10.20473/jbe.v5i2.2017.152-162.
[4] E. Mahawati, M. Pakpahan, and F. Wulandari, Penyakit Berbasis Lingkungan. Yayasan Kita Menulis, 2021.
[5] S. G. Purnama, Buku Ajar Penyakit Berbasis Lingkungan. 2016.
[6] Kementerian Hukum dan Hak Asasi Manusia Republik Indonesia, “Peraturan Pemerintah RI No 14 tentang Perumahan dan Kawasan Pemukiman,” 2016.
[7] Masriadi, Epidemiologi penyakit menular, 2nd ed. Depok: Rajawali Pers, 2017.
[8] Kementerian Kesehatan Republik Indonesia, “Hasil Riset Kesehatan Dasar Tahun 2018,” in Kementrian Kesehatan RI, vol. 53, no. 9, Badan Penelitian dan Pengembangan Kesehatan, 2018, pp. 1-22-.
[9] G. Sekar Prihanti1, . S., and I. Rahmawati, “Analisis Faktor Risiko Kejadian Tuberkulosis Paru,”
Saintika Med., vol. 11, no. 2, p. 127, 2017, doi: 10.22219/sm.v11i2.4207.
[10] Kementerian Kesehatan Republik Indonesia, “Keputusan Menteri Kesehatan Republik Indonesia Nomor 829/Menkes/SK/VII/1999 tentang Persyaratan Keseahatan Perumahan,” 1999.
[11] N. Agustina Ayu Wulandari and M. S. Adi, “Faktor Risiko dan Potensi Penularan Tuberkulosis Paru di Kabupaten Kendal , Jawa Tengah,” J. Kesehat. Lingkung. Indones., vol. 14, no. 1, pp. 7–13, 2015, doi: 10.1299/kikaic.57.382.
[12] S. T. Zulaikhah, R. Ratnawati, N. Sulastri, E. Nurkhikmah, and N. D. Lestari, “Hubungan Pengetahuan, Perilaku dan Lingkungan Rumah dengan Kejadian Transmisi Tuberkulosis Paru di Wilayah Kerja Puskesmas Bandarharjo Semarang,” J. Kesehat. Lingkung. Indones., vol. 18, no. 2, p. 81, 2019, doi: 10.14710/jkli.18.2.81-88.
[13] Mudiyono, W. N. Endah, and M. S. Adi, “Hubungan Antara Perilaku Ibu dan Lingkungan Fisik Rumah dengan Kejadian Tuberkulosis Paru Anak di Kota Pekalongan,” J. Kesehat. Lingkung.
Indones., vol. 14, no. 2, pp. 45–50, 2015.
[14] Kusrianti and A. Said, “Faktor Risiko Kejadian Penyakit Tuberkulosis BTA Positif di Wilayah Kerja Puskesmas Puuwatu Kota Kendari,” Miracle J. Public Heal., vol. 2, no. 2, pp. 201–209, 2019.
[15] S. Oktavia, R. Mutahar, and S. Destriatania, “Analisis Faktor Risiko Kejadian Tb Paru Di Wilayah Kerja Puskesmas Kertapati Palembang,” J. Ilmu Kesehat. Masy., vol. 7, no. 2, pp. 124–138, 2016.
[16] J. Buton and L. Ali, “Faktor Risiko Kejadian Penyakit Tuberkulosis Paru BTA Positif di Wilayah Kerja Puskesmas Wajo Kota Bau-Bau,” Miracle J. Public Heal., vol. 1, no. 2, pp. 1–12, 2018.
[17] F. Fahdhienie, A. Agustina, and P. V. Ramadhana, “Analisis Faktor Risiko Terhadap Kejadian Penyakit Tuberkulosis Di Wilayah Kerja Puskesmas Pidie Kabupaten Pidie Tahun 2019,” Sel J.
Penelit. Kesehat., vol. 7, no. 2, pp. 52–60, 2020, doi: 10.22435/sel.v7i2.3735.
[18] Menteri Kesehatan Republik Indonesia, “Peraturan Menteri Kesehatan Indonesia No 1077/Menkes/PER/2011,” 2011.
[19] O. R. P. P. Nike Monintja, Finny Warouw, “Hubungan antara Keadaan Fisik Rumah dengan Kejadian Tuberkulosis Paru Nike,” Indones. J. Public Heal. Community Med., vol. 1, no. 3, pp. 94–
100, 2020.
[20] M. Sultan, Higiene industri : penerapan di sektor perusahaan, 1st ed. Madza Media, 2021.
