Analisis Drug Resistance Dan Multi-Drug Resistance Tuberculosis Pada Previously Treated Cases Dengan Strategi Dots Di Kabupaten Deli Serdang Tahun 2004
ANALIS IS DRUG RESISTANCE DAN MUL TI-DRUG RESISTANCE
TUBERCULOSIS PADA PREVIOUSLY TREATED CASES
DENGAN STRATEGI DOTS DI KABUPATEN DELI SERDANG
TAHUN 2004
TE SIS
OLEH
ZULKARNAIN
0270230211Epid
PROGRAM MAGISTER ADMINISTRASI DAN KEBIJAKAN KESEHATAN
PEMINA TAN ADMINISTRASI KESEHATAN KOMUNITAS/EPIDEMIOlOGI
SEKOlAH PASCASARJANA
UNIVERSITAS SUMATERA UTARA
MEDAN
2005
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
RINGKASAN
ANALISIS DRUG RESISTANCE DAN MULTI-DRUG RESISTANCE
TUBERCULOSIS PADA PREVIOUSLY TREATED CASES
DENGAN STRATEGI DOTSDI KABUPATEN DELI SERDANG
TAHUN2004
Pengobatan yang tidak teratur, kombinasi obat yang tidak adekuat diduga
menimbulkan resistensi (Drug Resistance TB = DR-TB) dan resistensi ganda
Mycobacterium tuberculosis terhadap obat antituberkulosis (OAT) atau Multidrug
Resistant Tuberculosis (MDR-TB). DR-TB adalah resistensi Mycobacterium
tuberculosis terhadap salah satu komponen obat antituberkulosis dan MDR-TB
didefinisikan sebagai resistensi menyeluruh terhadap komponen OAT atau setidaktidaknya resistensi terhadap rifampisin dan isoniazid dengan atau tanpa resisten
terhadap obat lain. Setiap obat yang aktif menyerang kuman Mycobaterium
tuberculosis dapat menseleksi kuman sensitif sehingga terjadi resistensi, Hampir
seluruh negara didunia telah ditemukan kasus resistensi terhadap OAT.
Penanggulangan tuberkulosa dengan strategi Directly Observed Treatment
Shortcourse (DOTS) atau pengawasan langsung menelan obat jangka pendek (setiap
hari) dapat memberikan angka kesembuban yang tinggi, Penanggulangan TB-Paru
pada penderita dengan kuman TB sensitif memerlukan waktu pengobatan 6 bulan,
namun untuk penderita TB yang resisten (MDR-TB) harus menggunakan OAT lini
kedua yang sangat mahal (100 kali biaya pengobatan TB-Paru non MDR-TB),
disamping angka kesembuhannya yang tidak dijamin dan efek samping yang sangat
toksis, juga memerlukan jangka waktu penyembuban yang sangat lama.
Penderita TB yang menjalani pengobatan ulang (retreatment) disebabkan oleh
lalai atau berhenti sebelum akhir pengobatan (defaulted), kambub (relaps) dan gagal
dalam pengobatan (failure) adalah kelompok penderita TB yang termasuk kasus
penderita TB yang sebelumnya telah terpapar OAT (previously treated cases) dapat
mempengaruhi terjadinya resistensi tehadap OAT.
Untuk mengetahui pola resistensi, perbedaan proporsi penderita TB gagal,
kambub dan lalai berdasarkan karakteristik penderita dan adanya hubungan terjadinya
resistensi diantara penderita TB gaga!, kambub dan lalai dilakukan penelitian uji
sensitivitas kuman terhadap komponen OAT melalui pendekatan studi case series dan
cross sectional terhadap seluruh penderita TB gagal, kambub dan lalai yang
melakukan pengobatan dengan strategi DOTS di Kabupaten Deli Serdang peri ode
September - Desember 2004 sebanyak 32 kasus yang diperoleh dari kartu TB 01.
Hasil analisa statistika menggunakan uji Fisher Exact menunjukkan bahwa terdapat
perbedaan yang signifikan proporsi tingkat pendidikan (p value = 0,050), peminum
alkohol (p value = 0,032) dan merokok (p value = 0,035) diantara previously treated
cases, penderita Lalai lebih banyak berpendidikan rendah, peminum alkohol dan
merokok dibanding penderita gagal, kambub. Terdapat perbedaan yang signifikan
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
proporsi riwayat kontak (p value = 0,050) diantara previously treated cases, penderita
gagal, kambuh lebih banyak yang mempunyai riwayat kontak dibandingkan dengan
penderita Ialai. Tidak ada perbedaan yang signifikan proporsi previously treated cases
berdasarkan umur (p value = 0,374), jenis kelamin (p value = 1,000) dan penyakit
Diabetes melIitus yang menyertai (p value = 0,134).
Hasil uji sensitivitas kuman Mycobacterium tuberculosis terhadap kornponen
OAT yang diperoleh dari 32 previously treated cases seluruhnya telah terinfeksi
kuman Mycobacterium tuberculosis resisten terhadap komponen OAT, dengan MDRTB sebesar 28, I %. Ada hubungan yang signifikan antara faktor gagal, kambuh dan
lalai terhadap teIjadinya DR-TBI MDRTB (p value = 0,035), penderita Ialai lebih
besar untuk menjadi MDR dibandingkan penderita gagal, kambuh.
Untuk keberhasilan program penanggulangan tuberkulosis dan mencegah
terjadinya resistensi perlu penguatan dalam managemen TB kontrol untuk
memastikan tidak terjadi penghentian pengobatan (defaulted). Sangat perlu dilakukan
uji sensitivitas kuman Mycobacterium tuberculosis terhadap seluruh previously
treated cases sebagai dasar mengevaluasi regimen pengobatan selanjutnya.
Kata Kunci : Drug Resistance; Multidrug Resistance; Tuberculosis; Failed; Relaps;
Defaulted
u
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
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Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
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Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
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TUBERCULOSIS PADA PREVIOUSLY TREATED CASES
DENGAN STRATEGI DOTS DI KABUPATEN DELI SERDANG
TAHUN 2004
TE SIS
OLEH
ZULKARNAIN
0270230211Epid
PROGRAM MAGISTER ADMINISTRASI DAN KEBIJAKAN KESEHATAN
PEMINA TAN ADMINISTRASI KESEHATAN KOMUNITAS/EPIDEMIOlOGI
SEKOlAH PASCASARJANA
UNIVERSITAS SUMATERA UTARA
MEDAN
2005
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
RINGKASAN
ANALISIS DRUG RESISTANCE DAN MULTI-DRUG RESISTANCE
TUBERCULOSIS PADA PREVIOUSLY TREATED CASES
DENGAN STRATEGI DOTSDI KABUPATEN DELI SERDANG
TAHUN2004
Pengobatan yang tidak teratur, kombinasi obat yang tidak adekuat diduga
menimbulkan resistensi (Drug Resistance TB = DR-TB) dan resistensi ganda
Mycobacterium tuberculosis terhadap obat antituberkulosis (OAT) atau Multidrug
Resistant Tuberculosis (MDR-TB). DR-TB adalah resistensi Mycobacterium
tuberculosis terhadap salah satu komponen obat antituberkulosis dan MDR-TB
didefinisikan sebagai resistensi menyeluruh terhadap komponen OAT atau setidaktidaknya resistensi terhadap rifampisin dan isoniazid dengan atau tanpa resisten
terhadap obat lain. Setiap obat yang aktif menyerang kuman Mycobaterium
tuberculosis dapat menseleksi kuman sensitif sehingga terjadi resistensi, Hampir
seluruh negara didunia telah ditemukan kasus resistensi terhadap OAT.
Penanggulangan tuberkulosa dengan strategi Directly Observed Treatment
Shortcourse (DOTS) atau pengawasan langsung menelan obat jangka pendek (setiap
hari) dapat memberikan angka kesembuban yang tinggi, Penanggulangan TB-Paru
pada penderita dengan kuman TB sensitif memerlukan waktu pengobatan 6 bulan,
namun untuk penderita TB yang resisten (MDR-TB) harus menggunakan OAT lini
kedua yang sangat mahal (100 kali biaya pengobatan TB-Paru non MDR-TB),
disamping angka kesembuhannya yang tidak dijamin dan efek samping yang sangat
toksis, juga memerlukan jangka waktu penyembuban yang sangat lama.
Penderita TB yang menjalani pengobatan ulang (retreatment) disebabkan oleh
lalai atau berhenti sebelum akhir pengobatan (defaulted), kambub (relaps) dan gagal
dalam pengobatan (failure) adalah kelompok penderita TB yang termasuk kasus
penderita TB yang sebelumnya telah terpapar OAT (previously treated cases) dapat
mempengaruhi terjadinya resistensi tehadap OAT.
Untuk mengetahui pola resistensi, perbedaan proporsi penderita TB gagal,
kambub dan lalai berdasarkan karakteristik penderita dan adanya hubungan terjadinya
resistensi diantara penderita TB gaga!, kambub dan lalai dilakukan penelitian uji
sensitivitas kuman terhadap komponen OAT melalui pendekatan studi case series dan
cross sectional terhadap seluruh penderita TB gagal, kambub dan lalai yang
melakukan pengobatan dengan strategi DOTS di Kabupaten Deli Serdang peri ode
September - Desember 2004 sebanyak 32 kasus yang diperoleh dari kartu TB 01.
Hasil analisa statistika menggunakan uji Fisher Exact menunjukkan bahwa terdapat
perbedaan yang signifikan proporsi tingkat pendidikan (p value = 0,050), peminum
alkohol (p value = 0,032) dan merokok (p value = 0,035) diantara previously treated
cases, penderita Lalai lebih banyak berpendidikan rendah, peminum alkohol dan
merokok dibanding penderita gagal, kambub. Terdapat perbedaan yang signifikan
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
proporsi riwayat kontak (p value = 0,050) diantara previously treated cases, penderita
gagal, kambuh lebih banyak yang mempunyai riwayat kontak dibandingkan dengan
penderita Ialai. Tidak ada perbedaan yang signifikan proporsi previously treated cases
berdasarkan umur (p value = 0,374), jenis kelamin (p value = 1,000) dan penyakit
Diabetes melIitus yang menyertai (p value = 0,134).
Hasil uji sensitivitas kuman Mycobacterium tuberculosis terhadap kornponen
OAT yang diperoleh dari 32 previously treated cases seluruhnya telah terinfeksi
kuman Mycobacterium tuberculosis resisten terhadap komponen OAT, dengan MDRTB sebesar 28, I %. Ada hubungan yang signifikan antara faktor gagal, kambuh dan
lalai terhadap teIjadinya DR-TBI MDRTB (p value = 0,035), penderita Ialai lebih
besar untuk menjadi MDR dibandingkan penderita gagal, kambuh.
Untuk keberhasilan program penanggulangan tuberkulosis dan mencegah
terjadinya resistensi perlu penguatan dalam managemen TB kontrol untuk
memastikan tidak terjadi penghentian pengobatan (defaulted). Sangat perlu dilakukan
uji sensitivitas kuman Mycobacterium tuberculosis terhadap seluruh previously
treated cases sebagai dasar mengevaluasi regimen pengobatan selanjutnya.
Kata Kunci : Drug Resistance; Multidrug Resistance; Tuberculosis; Failed; Relaps;
Defaulted
u
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
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Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
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Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
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Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008
Zulkarnain : Analisis drug resistance dan multi-drug resistance tuberculosis...,2005.
USU e-Repository © 2008