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INT J TUBERC LUNG DIS 5(10):920–925© 2001 IUATLD

High tuberculosis notification and treatment success rates through community participation in central Sulawesi,Republic of Indonesia

M. Becx-Bleumink,* H. Wibowo,† W. Apriani,† H. Vrakking*

S U M M A R Y

* KNCV, The Hague, The Netherlands; † Communicable Disease Control (CDC), Palu, Central Sulawesi, Indonesia

SETTING: Central Sulawesi Province, Republic ofIndonesia.OBJECTIVE: To increase tuberculosis case notificationand maintain high treatment success rates through com-munity participation in a tuberculosis field programme.DESIGN: Comparison of tuberculosis case notificationand treatment results in a community based tuberculosisprogramme (CBTP), before and after introduction of theprogramme and between areas where the programmewas and was not introduced.RESULTS: During 1998, the CBTP was introduced intwo of the four rural districts of the Central Sulawesiprovince, covering 224 (29%) of the 772 villages and362 700 (33%) of the 1 109 100 population in these dis-tricts. In the CBTP villages the notification rate of newsmear-positive patients per 100 000 population in-creased from 51 in 1996 and 48 in 1997 to 166 in 1998.In the 548 non-CBTP villages the rates were 62, 60 and

70, respectively. The sputum conversion rate at the endof the first 2 months of the treatment was over 85% inboth the CBTP and the non-CBTP villages. In the CBTPvillages the treatment success rate (cure and treatmentcompletion) was 90.4%, 89.5% and 93.7% in 1996,1997, and 1998. For the non-CBTP villages these rateswere respectively 85.4%, 86.8% and 85.9%. In 1998the sputum conversion and treatment success rates weresignificantly higher in the CBTP villages than in the non-CBTP villages.CONCLUSION: Through community participation, thenotification of new smear-smear positive patients in-creased substantially, while sputum conversion andtreatment success rates remained high.KEY WORDS: tuberculosis control; community partici-pation; community based tuberculosis control; case no-tification; treatment results

INDONESIA is one of the countries where tuberculo-sis is a major health problem. In 1999 the WorldHealth Organization (WHO) estimated that 590 000persons developed tuberculosis each year in Indone-sia, which is equivalent to 282 per 100 000 popula-tion. The annual incidence of new smear-positive pa-tients was estimated at 265 000, which is equivalentto 127/100 000.1

During 1993, a pilot project whereby weekly di-rectly observed treatment was given by health centrestaff during the initial 2 months and fortnightly dur-ing the remaining 4 months was introduced in eighthealth centres of the Central Sulawesi province. Itwas implemented in all 103 health centres of theprovince during 1995.

Since the start of the project the sputum conver-sion rate among new smear-positive patients has been80% and over, and the treatment success rate (curewith confirmed bacteriology and treatment comple-

tion) above 85%. The notification rate of new smear-positive patients increased from 31/100 000 during1995 to 56 during 1997, which can be explained bythe involvement of hospitals and private practitionersand increasing awareness among health centre staffabout the selection of suspect tuberculosis cases.

The annual incidence of smear-positive pulmonarycases in Central Sulawesi is not known. For the calcu-lation of notified patients as a percentage of estimatedpatients, the average national annual incidence ofsmear-positive tuberculosis cases of 127/100000 pop-ulation was used as denominator. Based on this it wasconcluded that fewer than 50% of smear-positive pa-tients are detected. From discussions with supervisorsand health centre staff it was concluded that the ser-vices were not reaching the people in remote areaswho depended mainly on sub-centres that did notprovide tuberculosis control services. Furthermore,cultural beliefs, shame at being known to be tubercu-

Correspondence to: Dr Marijke Becx-Bleumink, Senior Consultant Tuberculosis, Royal Netherlands Tuberculosis Associa-tion, PO Box 146, 2501 CC The Hague, The Netherlands. Tel: (�31) 70 390 6112. Fax: (�31) 70 390 6175. e-mail:[email protected] submitted 28 February 2001. Final version accepted 23 July 2001.

TB control through community participation 921

lous, lack of money to pay for transport to attend ahealth centre, and lack of awareness about free diag-nosis and treatment may prevent patients from com-ing forward for diagnosis and treatment.

In order to increase notification of smear-positivepatients and maintain high treatment success rates acommunity based tuberculosis programme (CBTP)was introduced in 1998. This paper describes thesteps that have been taken to mobilise communitieson tuberculosis and train sub-centre health workersin delivery, observation and recording of treatment.Notification data on new smear-positive patients andtreatment results before and after introduction of theCBTP are presented and discussed. The data of theCBTP villages are compared with those of the remain-ing villages (referred to as non-CBTP villages).

SETTING

The Central Sulawesi province consists of five dis-tricts, four rural districts and a municipality, with atotal population of just over 2 million at the end of1998.

Details about detection, diagnosis and treatmentof tuberculosis patients before the CBTP was intro-duced have been published previously.2 In short, case-detection is done through sputum smear examinationof patients presenting at a health centre with suspecttuberculosis, diagnosis is by sputum smear-micros-copy carried out in selected health centres, and treat-ment is given in all health centres upon prescriptionby a medical officer or trained nurse. All patients witha diagnosis of new smear-positive tuberculosis aretreated daily with four drugs (rifampicin, isoniazid,pyrazinamide and ethambutol) for the first 2 months,followed by rifampicin and isoniazid three timesweekly for 4 months. At the onset of treatment a boxof drugs is reserved for each patient. The patient is re-quested to identify a household member or othercommunity member for observation of treatment athome, six times per week during the first 2 months andfive times per fortnight during the last 4 months. Drugsare provided in blister packs containing the drugs forone day.

Samples of smears for all smear-positive patientsand for 10% of smear-negative suspects are routinelyre-examined by provincial laboratory technicians,with the readers being blinded to the result of the pe-ripheral laboratory. Over the years concordance ofresults between the peripheral laboratories and thereference laboratory has been over 95%.

METHODS

During 1998 the CBTP was introduced in 224 (29%)of the 772 villages of two rural districts, covering362 700 (33%) of the 1 109 100 population of thesedistricts.

To select participating communities, and to mobil-ise and train the community and sub-centre healthworkers, the following steps were taken:

Health centres were selected by provincial and dis-trict staff. Selection criteria were higher-than-averagetreatment results—sputum conversion and treatmentoutcome—during the previous 2 years. The provin-cial and district tuberculosis supervisors and healthcentre staff met to discuss the purpose of the CBTP,after which villages were selected by health centrestaff and approved by the district supervisor.

Health education was provided and informationdisseminated to the leaders of the selected villagers,including the village heads, religious leaders andmembers of special groups such as Women’s Associa-tions. Health education was also provided to thecommunity, in co-operation with the leaders, in orderto: 1) convince the people that tuberculosis is a villagehealth problem and that infectious tuberculosis pa-tients can infect their family and community members;2) explain about the disease, its symptoms, and diag-nosis; 3) explain that the disease can be cured, that di-agnosis and treatment are available free of charge, andthat treatment can be most successful through commu-nity participation, and 4) encourage patients withchronic cough to go to the village hall or health centreto have their sputum taken for examination.

Sub-centre health workers and village midwiveswere trained in selection of tuberculosis suspects, de-livery and observation of treatment, including selec-tion and guidance of household members, and recordkeeping.

After diagnosis at a health centre or hospital thepatients are registered at the sub-centre in their vil-lage. Sub-centres are under the responsibility of ahealth centre and they serve a number of villageswhose populations vary from a few hundred to sev-eral thousand. During the intensive phase of treat-ment patients attend the sub-centre once weeklywhen the treatment for that day is given under directobservation. During the continuation phase patientsattend the sub-centre every fortnight. The drugs forthe remaining days are given to the patient in blisterpacks. A household member is requested to observethe treatment at home; the name of the treatment ob-server is written on the Patient Record Card.

Diagnosed patients are known in the community,and the members of the community are expected tosupport them. Patients who do not want to be knownas tuberculous for whatever reason have the choice ofvisiting the health centre for weekly and fortnightlyobservation of treatment and collection of drugs.They are also requested to select a household memberfor observation of treatment at home.

In order to guide and supervise the implementationof the CBTP, health centre staff visit the villages reg-ularly, initially monthly and thereafter every 2 months.The district tuberculosis supervisors supervise the

922 The International Journal of Tuberculosis and Lung Disease

participating health centres with the same frequency.The health centres in the non-CBTP areas are visitedquarterly according to routine policy. Funds for visitsby health centre staff and supervision by tuberculosissupervisors are obtained from external sources.

The Tuberculosis Treatment Cards, District Tuber-culosis Register, recording and reporting forms arethose recommended by the International UnionAgainst Tuberculosis and Lung Disease (IUATLD).3

Notification rates are expressed as numbers of newsmear-positive patients notified during a year per100 000 population. Sputum conversion data andtreatment results are routinely reported by district forquarterly cohorts of patients. For the purpose of thisstudy, data on notification, conversion and treatmentresults were separate for the CBTP villages and thenon-CBTP villages, retrospectively for 1996 and1997 and prospectively for 1998.

Conversion and treatment outcome data were en-tered into Epi-Info version 6.0 software (CDC, At-

lanta, GA). Treatment outcomes of patients in theCBTP villages were compared with those of patientsin the non-CBTP villages, using the �2 test with differ-ences at the 5% level being regarded as significant.

RESULTS

For 1996 and 1997 the notification rates per 100 000population were 51 and 48, respectively, in the CBTPvillages, and 62 and 60 in the non-CBTP villages (Ta-ble 1). During 1998 the rate more than tripled to 166in the CBTP villages, and increased slightly to 70 inthe non-CBTP villages.

Sputum conversion results at the end of the first 2months of the treatment are presented in Table 2. For1996 and 1997 the conversion rate is higher in theCBTP villages, but the difference is not statistically sig-nificant. For 1998 the conversion rate is significantlyhigher for patients treated in the CBTP villages.

The percentage of patients with positive smears atthe end of the first 2 months of treatment decreasedsignificantly over the years in both the CBTP and thenon-CBTP villages.

Treatment results are given in Table 3. During thethree years covered by the study, the treatment suc-cess rate (cure plus treatment completion) is above85% in both the CBTP and the non-CBTP villages.The rate is higher in the CBTP than in the non-CBTPvillages. For 1996 and 1997 the difference is not sta-tistically significant, but for 1998 the treatment suc-cess rate is significantly higher in the CBTP villages.The decline in failure rate in both the CBTP and thenon-CBTP villages is statistically significant.

Table 1 Numbers of new smear-positive patients notified and case-notification rates per 100 000 population in CBTP and non-CBTP villages in two rural districts of Central Sulawesi

Year

CBTP village Non-CBT villageTotal

Patientsn CNR

Patients n CNR

Patientsn CNR

1996 177 51 444 62 621 581997 171 48 439 60 610 561998 603 166 519 70 1.122 101

CBTP � Community Based Tuberculosis Programme; CNR � case notificationrate of new smear-positive patients per 100 000 population.

Table 2 Sputum conversion at the end of the first 2 months of treatment in CBTPand non-CBTP villages in two rural districts of Central Sulawesi

CBTPn (%)

non-CBTPn (%) �2 P

1996 n � 177 n � 444ResultSmear-negative 160 (90.4) 387 (87.2) 0.97 0.32Smear-positive 14 (7.9) 33 (7.4)Other* 3 (1.7) 24 (5.4)



Comparison over the yearsSmear-negatives, CBTP 3.04 0.22Smear-negatives, non-CBTP 1.69 0.43Smear-positives, CBTP 17.96 �0.01Smear-positives, non-CBTP 9.26 0.01

* Patients still on treatment at the end of the first 2 months, but who had no smear examination, died or were trans-ferred out.CBTP � Community Based Tuberculosis Programme.


DISCUSSION

When short-course chemotherapy was introduced inCentral Sulawesi as part of a package which has beenknown as the DOTS strategy since 1996, the first pri-ority was to cure at least 85% of new smear-positivepatients diagnosed at health centres.2 The extensionof the strategy to hospitals and private practitionersled to an increase in case-notification; however, fewerthan 50% of estimated smear-positive patients werediagnosed and treated. Tuberculosis diagnosis andtreatment through case finding at health centresand hospitals apparently does not become accessibleto part of the population living in rural areas.

By involving community health workers and com-munity leaders, identification of tuberculosis suspectsand treatment of patients was made as accessible to thepatients as possible, and the communities assumed re-sponsibility for patient adherence to treatment. Notifi-cation of new smear-positive patients more than tri-pled in the CBTP villages. Sputum conversion andtreatment success rates rose to over 85%, and, after the

CBTP was introduced, were even significantly higherin the CBTP villages than in the non-CBTP villages.

We have no explanation for the decline in percent-age of patients with positive smears at the end of thefirst 2 months of treatment. The decline in percentageof treatment failures may be related to the decline inpositive smear results at 2 months.

The strengths of the CBTP are that the programmewas based on observations by health workers that thetuberculosis control services do not reach many peoplein rural areas, and that it is implemented under rou-tine field conditions. The weakness of the comparisonbetween CBTP and non-CBTP villages is that the vil-lages were not selected randomly. Only after theCBTP had been implemented did retrospective analy-sis of conversion rates and treatment results of 1996and 1997 show that the differences between theCBTP and non-CBTP villages were not statisticallysignificant and that comparison after implementationof the CBTP was therefore justified.

During recent years, community involvement inTB control has been given more attention. The in-

Table 3 Treatment results in CBTP and non-CBTP villages in two rural districtsof Central Sulawesi

CBTPn (%)

Non-CBTPn (%) �2 P

1996 n � 177 n � 444Outcome category

Cured 141 (79.7) 339 (76.4)Treatment completed 19 (10.7) 40 (9.0)Treatment failure 3 (1.7) 11 (2.5)Died 4 (2.3) 29 (6.5)Defaulted 8 (4.5) 18 (4.1)Transferred out 2 (1.1) 7 (1.6)

Total treatment success 160 (90.4) 379 (85.4) 2.38 0.12


Cured 136 (79.5) 349 (79.5)Treatment completed 17 (9.9) 32 (7.3)Treatment failure 2 (1.2) 5 (1.1)Died 8 (4.7) 25 (5.7)Defaulted 8 (4.7) 27 (6.2)Transferred out — 1 (0.2)

Total treatment success 153 (89.5) 381 (86.8) 0.59 0.44


Cured 533 (88.4) 417 (80.3)Treatment completed 32 (5.3) 29 (5.6)Treatment failure 1 (0.2) 3 (0.6)Died 23 (3.8) 17 (3.3)Defaulted 10 (1.7) 47 (9.1)Transferred out 4 (0.7) 6 (1.2)

Total treatment success 565 (93.7) 446 (85.9) 18.00 �0.01

Comparison over the yearsTotal treatment success, CBTP 4.50 0.11Total treatment success, non-CBTP 0.38 0.83Treatment failure, CBTP 6.07 0.05Treatment failure, non-CBTP 6.68 0.04

CBTP � Community Based Tuberculosis Programme; Cured � smear-negative at the end of treatment; Treatmentcompleted � no bacteriological confirmation of cure; Treatment failure � smear-positive at 5 months or more afterthe start of treatment; Died � patient died during treatment, whatever the cause of death; Defaulted � patient didnot attend for treatment for 2 consecutive months or more; Transferred out � transferred to a health care unit out-side the district.

924 The International Journal of Tuberculosis and Lung Disease

creasing number of tuberculosis patients with associ-ated human immunodeficiency virus infection makesclinic and particularly hospital care in many countriesno longer feasible.4–7 It is clear that the main role ofcommunities in tuberculosis care should be to ensurepatients’ adherence to treatment, consequently achiev-ing high treatment success rates.8–10 In a recent publi-cation, a summary is given of published studies de-scribing community contribution to tuberculosis care.8These studies exclusively concern delivery of treat-ment by a community worker, ranging from lay vol-unteers to village doctors. Satisfactory treatment re-sults with 80–90% success rates are reported. In otherstudies, special groups of people, such as students,11

traditional healers,12 or TB clubs13 are used or recom-mended for observation of treatment.

Very little has been published about experienceswith the use of community leaders to raise awarenessabout tuberculosis in communities. Raising commu-nity awareness about the signs and symptoms of adisease and the availability of free diagnosis andtreatment has successfully been carried out by a vari-ety of community leaders in the control of diseasessuch as leprosy and malaria.14–16

Because tuberculosis is often perceived as a chronicincurable disease,16 increasing the awareness of signsand symptoms of the disease and the possibilities forcure is likely to increase the number of patients whoattend the services for diagnosis and treatment, aswas shown in Central Sulawesi. Prerequisites are thatthe diagnostic services can cope with higher numberof smear examinations and that treatment for the in-creased number of diagnosed patients is guaranteed.

As an ongoing process, community participation islikely to be sustainable, because community leadersand health workers know the villagers. The followinglessons have been learnt from the experiences in Cen-tral Sulawesi:

• Although DOTS had been implemented success-fully in the entire province for 3 years, rural com-munities had little, if any, awareness about thedisease or the availability of free diagnosis andtreatment.

• CBTP can substantially increase case notificationand ensure high treatment success rates.

• Community participation may play an importantrole in making progress to attain the WHO-recom-mended targets of detecting 70% of smear-positivepatients and curing 85% of them.

During 1999 and 2000 the CBTP was expanded. Bythe beginning of 2001 it covered 561 (73%) of the772 villages in the two districts. It has been further in-troduced in the two remaining rural districts and themunicipality, covering 66 (10%) of the 648 villagesby the beginning of 2001. It is the intention that by

the year 2005 CBTP will be implemented in all of thevillages in the province.

AcknowledgementsOur thanks go to the provincial and district Tuberculosis/Leprosysupervisors, the staff of the participating health centres, and thecommunity leaders of the participating villages for their co-opera-tion, dedication and enthusiasm. The help of Mr P Eilers with sta-tistical analysis has been much appreciated.

References1 World Health Organization. Global DOTS Expansion Plan.

Progress in TB control in high-burden countries, 2001. Oneyear after the Amsterdam Ministerial Conference. Geneva:WHO, 2001.

2 Becx-Bleumink M, Djamaluddin S, Loprang F, de Soldenhoff R,Wibowo H, Aryono, M. High cure rates in smear-positive tuber-culosis patients using ambulatory treatment with once-weeklysupervision during the intensive phase in Sulawesi, Republic ofIndonesia. Int J Tuberc Lung Dis 1999; 3: 1066–1072.

3 Enarson D, Rieder H, Arnadottir T, Trébucq A. Tuberculosisguide for low income countries. Fourth ed. Paris, France:IUATLD, 1996.

4 Maher D, Hausler H P, Raviglione M R, et al. Tuberculosis carein community care organizations in sub-Saharan Africa: practiceand potential. Int J Tuberc Lung Dis 1997; 1: 276–283.

5 Squire S B, Wilkinson D. Strengthening “DOTS” through com-munity care for tuberculosis. BMJ 1997; 315: 1395–1396.

6 Banerjee A, Harries A D, Mphasa N, et al. Evaluation of a uni-fied treatment regimen for all new cases of tuberculosis usingguardian-based supervision. Int J Tuberc Lung Dis 2000; 4:333–339.

7 Wilkinson D. High-compliance tuberculosis treatment pro-gramme in a rural community. Lancet 1994; 343: 647–648.

8 Maher D, van Gorkom J L C, Gondrie P C F M, Raviglione M.Community contribution to tuberculosis care in countries withhigh tuberculosis prevalence: past, present and future. Int J Tu-berc Lung Dis 1999; 3: 762–768.

9 Akkslip S, Rasmitat S, Maher D, Sawert H. Direct observationof tuberculosis treatment by supervised family members inYasothorn Province, Thailand. Int J Tuberc Lung Dis 1999; 3:1061–1065.

10 Kamolratanakul P. Randomized controlled trial of directly ob-served treatment (DOT) for patients with pulmonary tuber-culosis in Thailand. Trans R Soc Trop Med Hyg 1999; 93:552–557.

11 Rajeswar R, Chandrasekan K, Thiruvalluvan E, et al. Study ofthe feasibility of involving male student volunteers in caseholding in an urban tuberculosis programme. Int J TubercLung Dis 1997; 1: 573–575.

12 Wilkinson D, Gcabashe L, Lurie M. Traditional healers astuberculosis treatment supervisors: precedent and potential.Int J Tuberc Lung Dis 1999; 3: 838–842.

13 Getahun H, Maher D. Contribution of ‘TB clubs’ to tuberculo-sis control in a rural district in Ethiopia. Int J Tuberc Lung Dis2000; 4: 174–178.

14 Kumar A, Thangavel N, Durgambal K, Anabalagan M. Com-munity leaders involvement in leprosy health education. Int JLep 1984; 56: 901–911.

15 Garfield R, Vermund S H. Health education and communityparticipation in mass drug administration for malaria in Nica-ragua. Soc Sci Med 1986; 22: 869–877.

16 Hadley M, Maher D. Community involvement in tuberculosiscontrol: lessons from other health care programmes. Int J Tu-berc Lung Dis 2000; 4: 401–408.


R É S U M É

CADRE : La Province Centrale de Sulawesi, Républiqued’Indonésie.OBJECTIF : Augmenter le taux de déclaration des cas detuberculose et maintenir des taux élevés de succès dutraitement grâce à la participation de la collectivité à unprogramme de tuberculose sur le terrain.SCHÉMA : Comparaison des déclarations des cas de tu-berculose et des résultats du traitement dans un pro-gramme basé sur la collectivité (CBTP), respectivementavant et après l’introduction du programme ainsi qu’en-tre les zones où le programme était ou n’était pas mis enœuvre.RÉSULTATS : Au cours de l’année 1998, le CBTP a étéintroduit dans deux des quatre districts ruraux de laProvince centrale du Sulawesi et a couvert 224 (29%)des 772 villages et 362.700 (33%) des 1.109.100 habi-tants de ces districts. Dans les villages CBTP, le taux dedéclaration des nouveaux patients à bacilloscopie posi-tive pour 100.000 habitants a augmenté de 51 au coursde l’année 1996 et 48 au cours de 1997 jusque 166 pen-

dant l’année 1998. Dans les 548 villages non-CBTP, lestaux étaient respectivement de 62, 60 et 70. Le taux denégativation de l’expectoration à la fin des deux pre-miers mois de traitement était supérieur à 85% tant dansles villages CBTP que dans les villages non-CBTP. Dansles villages CBTP, les taux de succès du traitement(guérison ou achèvement du traitement) étaient respec-tivement de 90,4%, 89,5% et 93,7% au cours desannées 1996, 1997 et 1998. Pour les villages non-CBTP,ces taux étaient respectivement de 85,4%, 86,8% et85,9%. Au cours de l’année 1998, les taux de négativa-tion de l’expectoration et de succès du traitement sontsignificativement plus élevés dans les villages CBTP quedans les villages non-CBTP.CONCLUSION : Grâce à la participation de la collectivité,la déclaration des nouveaux cas de tuberculose à bacil-loscopie positive a augmenté de façon substantielle alorsque les taux de négativation et les taux de succès dutraitement restaient élevés.

R E S U M E N

MARCO DE REFERENCIA : Provincia Central de Su-lawesi, República de Indonesia.OBJETIVO : Aumento en la notificación de casos detuberculosis y mantenimiento de altas tasas de éxito tera-péutico a través de la participación de la comunidad enun programa de tuberculosis de campo.MÉTODO : Comparación de la notificación de casos detuberculosis y de los resultados del tratamiento en unPrograma de Tuberculosis Basado en la Comunidad(PTBC), antes y después de la introducción del pro-grama y entre áreas con y sin programas.RESULTADOS : Durante 1998 el PTBC fue introducidoen dos de los cuatro distritos rurales de la provincia Cen-tral Sulawesi, cubriendo 224 (29%) de 772 aldeas y362.700 (33%) de los 1.109.100 habitantes de estos dis-tritos. En las aldeas con PTBC la tasa de notificación delos nuevos pacientes con baciloscopía positiva por cada100.000 habitantes aumentó de 51 durante 1996 y 48 en

1997, a 166 en 1998. En las 548 aldeas sin PTBC lastasas fueron 62, 60 y 70, respectivamente. La tasa deconversión del esputo al final de los primeros 2 mesesde tratamiento estuvo por encima del 85% en las aldeascon PTBC, así como en las aldeas sin PTBC. En las al-deas con PTBC las tasas de éxito terapéutico (curación ytratamiento completo) fue del 90,4%, 89,5% y 93,7%durante 1996, 1997 y 1998, respectivamente. En las al-deas sin PTBC las tasas fueron 85,4%, 86,8% y 85,9%.En 1998 las tasas de conversión del esputo y del éxitoterapéutico fueron significativamente más altas en las al-deas con PTBC que en las que no lo tenían.CONCLUSIÓN : La notificación continuada de la parti-cipación de la comunidad de los pacientes con esputopositivo aumentó substancialmente, mientras que laconversión de los esputos y los éxitos terapéuticos per-manecieron altos.

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