resurgence of diphtheria in east java where do we are ?
DESCRIPTION
Resurgence of diphtheria in East Java where do we are ?. Ismoedijanto Balai besar Laboratorium kesehatan Surabaya, 09 10 2012. Propinsi versus kabupaten /kota …………………….kecuali yang melakukan ORI…. . KKK (kemana kemkes kita)…........ Hehehe….. Mohon maaf lahir batin. - PowerPoint PPT PresentationTRANSCRIPT
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Resurgence of diphtheria in East Java where do we are ?
IsmoedijantoBalai besar Laboratorium kesehatan
Surabaya, 09 10 2012
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Propinsi versus kabupaten /kota…………………….kecuali yang melakukan ORI….
KKK (kemana kemkes kita)…........Hehehe….. Mohon maaf lahir batin
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some view of a clinician
• Difteri sebagai penyakit menular (Clinical site)– Gambaran klinik, komplikasi dan pengobatan
• Difteri as one of VPD (vaccine preventable disease)– Mencegah kesakitan, kematian dan komplikasi
– Imunisasi imunogen difteri
• difteri serve as one of the indices – Indikator health services
– Indikator imunization services
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Report and presentation on East Java diphtheria
• Presentasi KLB difteri Bangkalan th 2005 di ACPID (Asian Congress of Pediatric Infectious Disease) ke 3, Cebu Philipina
• Diramalkan menjadi klb pada PIT IDAI th 2007, Yogyakarta• Pertemuan imunisasi, SO Jawa Timur 2007• Pertemuan SO ttg PD3I, Makassar 2008 mengingatkan difteri• Laporan KLB diferi Jawa Timur di KONIKA /ACPID 4, 2008, di
Surabaya• Meeting TAGI 2008,2009, ( rekomendasi Td ) , Satgas Imunisasi
IDAI 2009, 2010 , pertemuan Kemkes selama th 2009, 2010 , (tidak ada tahun 2011), bandung , denpasar , jakarta , bogor. Belum menjadi masalah, kedua terbanyak di dunia
• Pertemuan SO Batam october 2011, Bandung 2011
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Ten years past the elimination target date and the elimination goal has not been met.
Indigenous transmission continues: Latvia, Ukraine, Lithuania, Russian Federation and other NIS countries. Sporadic cases: EU member states.
Cases and large epidemics are still occurring in other parts of the world, South East Asia (Indonesia, India), Africa, Eastern Mediterranean, South America.
EPIDEMIC DIPHTHERIA IS STILL WITH US
WHO ELIMINATION GOAL FOR DIPHTHERIA
“The target for European member states was the elimination of indigenous diphtheria by the year 2000. This meant the
absence of indigenous cases caused by toxigenic Corynebacterium diphtheriae strains.”
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Clinical picture of diphtheria
Gejala, tatacara diagnosis, komplikasi
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Gambaran klinik Diphtheria
• Masa Inkubasi 2-5 days (range, 1-10 days)
• Tanda utama – Ada pseudomembran– Menghasilkan toksin
• site of infection– Anterior nasal– Tonsillar and pharyngeal– Laryngeal– Cutaneous– Ocular– Genital
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MANIFESTASI KLINIK
• Variasi gejala: tanpa gejala hipertoksik & fatal- Faktor-faktor:
- primer: imunitas, virulensi - toksinogenesitas., lokasi anatomis- lain-lain: umur, peny sistemik penyerta, kepadatan hunian,
peny pada nasofaring • Masa tunas: 2-6 hari• tanda klinik :
• Demam <38,50 C , tidak tinggi• nyeri telan • Membaik dalam 5 hari
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Death by suffocation
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Death by myocarditis
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Miokarditis dan AV block
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Other complications
• Palatum molle paralisis• Paralisis saraf kranial: diplopia, strabismus• Paralisis saraf perifer: tangan, kaki • Acute kidney injury• Endocarditis• Arthritis• osteomyleitis
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Surgical management
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Umum:
• istirahat mutlak ±2 minggu,
• cairan/ diit adekuat,
• jaga nafas tetap bebas, lakukan trakheostomi bila: gelisah, iritabel & gangguan pernafasan progresif
• komplikasi • Lakukan sonda nasogastrik bila ada paralisis palatum molle
• Tatalaksana miokarditis
• Tatalaksana AKI
• Tatalaksana paralisis
Medical management (1)
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Khusus:
• karena toksin menyebabkan kerusakan sel, perlu segera diberikan antitoksin/antibodi, karena penderita tidak mempunyai antibodi
-antitoksin; serum anti difteri (ADS) segera secara intramuskuler (kadar maksimal tercapai setelah 4 hari) atau intravena diencerkan dalam 200 ml garam faali dan diberikan selama 4 jam, sediakan adrenalin 1:1000 dalam semprit, kortikosteroid; didahului tes kulit/tes konjungtiva
Dosis ADS: 20.000 – 120.000 KI :
• 20.000 ringan difteri nasal dan permukaan
• 60.000 sedang : beslag sedang
• 100.000-120.000 berat: beslag luas, bullneck,toksik
Medical management (2)
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Dosage of anti-toxin
Type of diphtheria Dose (units) Route
Nasal 10 - 20 000 IM
Tonsillar 15 - 25 000 IM/IV
Pharyngeal or laryngeal 20 - 40 000 IM/IV
Combined or delayed 40 - 60 000 IV
Severe diphtheria 40 - 100 000 IV/both
Details in HPA Immunoglobulin handbook available at: http://www.hpa.org.uk/infections/topics_az/immunoglobulin/pdfs/diphtheria.pdf
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-antimikrobial: untuk menghentikan produksi toksin
Procain penic 50.000 – 100.000 KI/Kg/hari atau eritomisin 50 mg/Kg/hari selama 10 hari
-kortikosteroid: kontroversi
-pengobatan penyulit:
• terutama ditujukan menjaga hemodinamika tetap baik
• mengatasi gangguan fungsi pompa jantung
• NGT pada paralisis palatum mole
• Mengatasi gangguan fungsi ginjal
• Pengobatan paralisis perifer
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Diagnosis and outbreak• Hanya 40% penderita dengan kultur pos ok:
– Mendapat antibiotika– Salah cara pengambilan mis ditengah beslag– Salah media pertumbuhan – Salah tatacara kirim– Adanya kuman lain
• Adanya kasus yg terlambat, sudah dengan komplikasi (miokarditis), beslag sdh hilang
• Culture proven dan toxigenicity test• PCR dengan swab• Makin langkanya expertise• Overdiagnosis kasus terutama kasus dewasa
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RSPKMDPSMASYBPSLAB
RSPKMDPSMASYBPSLAB
RS
PKM
RS
PKMDPS DPS
2010 2011
Source of reports TAHUN 2010 - 2011
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0
5
1015
20
25
30
35
4045
50
55
60
" JAN
200
8M
aret
Mei Juli
Sept
Nop
"JAN
200
9M
aret
Mei Juli
Sept
Nop
"JAN
201
0M
aret
Mei Juli
Sept
Nop
"JAN
201
1M
aret
Mei Juli
Sept
Nop
TREND BULANAN KASUS DIPHTERI DI JATIM 2008 – 2011 ( 20 SEPT 2011 )
Pasca Idul fitri
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01 1
0
4 4 4
6
12
8
21
18 16 11 5 15
52 44
86 76
140
304
0
25
50
75
100
125
150
175
200
225
250
275
300
325
0
2
4
6
8
10
12
14
16
18
20
22
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
JML MATI JML Kasus
DISTRIBUSI KLB DIPHTERI DI JATIM TH 2000 – 2011
Tahun
Jml Mati665
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Sebaran difteri di Jatim
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(16 Mei )N = 31
1
N : 31
SEBARAN DIPHTERI DI JATIM s/d 9 November 2012
7 17/1
65/1
28/1 27 20/1
4
172
517
31
12 14 50/2
117/726
227
Jml kasus = 762Jml mati = 29Jml kab/ko = 38
3
19/1
6
89/11
823/110
16/1
124 8
21
518/1
6 7
53
WIL SUB PIN 2012
7/1
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Data & Informasi BBLKSUB 2012 26
Mapping Area C. diphtheria Patogenic & Toxigenic in East Java 2011 -2012
M
M
MM
MM
M
M
MM
MM
M
M+GM+B
M+I
M+BM+B
M+B
M+B
M+B
C difteri var. - Mitis (M)- Gravis (G)- Intermedius (I)- Belfanti (B)
SEBARAN “ C difteriae – Toxigenic “ PADA KLB DIPHTERI DI JATIM s/d 14 Juni
2012
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bwk keren
KASUS DIPHTERI DAN IMUNISASI DPT3 – DT-SD DI JAWA TIMUR s/d Jan 2010
0102030405060708090
100110120130140
KASUSDIPHTERI
DPT3
DT-SD
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97/98 98/99 99/200 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110
100
200
300
400
500
600
700
91 92 95.6 102 96 95 96 101 100.1 100.2 101.9 101.8 101.2 100 99.5
101 99 98.9 98 98 98 99 98.7 99 97.6 105.3 94.6 97.5 92.8 96.3
DPT3 DT-SD JML KASUS
KASUS DIPHTERI VS IMUNISASI DPT3 – DT-SD DI JAWA TIMUR
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COVERAGE SURVEY IMUNISASI 8 KAB/KOTA DI JATIM, 2009-2010
No Kab/KotaCakupan (%)
Lengkap Valid Dose1 Blitar 62.9 61.42 Jember 85.2 49.53 Bojonegoro 85.2 48.64 Malang 89.5 42.45 Lumajang 56.7 41.46 Surabaya 79.5 40.57 Bangkalan 68.6 31.98 Sumenep 55.7 15.2
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Case definition
• Clinical case:– Sore throat– Pseudomembrane– Kulit/conjunctiva/mukosa lainnya
• Probable:– Clinical case– Contact or linked to confirmed case
• Confirm case:– Probable/clinical– Pos culture and toxigenic
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case definitions /clinical criteria
WHO• respiratory
– and • pseudomembrane
EU• respiratory • nasal • cutaneous • other sites
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Peran lab untuk kasus KLB
WHO• Isolation of
C diphtheriae– or
• 4-fold rise in antibody titre
EU• Isolation of
toxin producing C.diphtheriae or C.ulcerans
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arti non-toxigenic C.diphtheriae
• Severe infections with non-toxigenic C.diphtheriae have been documented
• Namun , isolates sering didapat pula dari px le pharyngitis, sometimes with other organisms
• No need for clearance swabs or contact tracing
• Menjadi toxigenic bila terinfeksi bacteriophage dg gene tox pos
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Menentukan toksigenisitas kuman difteri
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Enhanced surveillance of laboratory confirmed toxigenic corynebacterium infections
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Data & Informasi BBLKSUB 2012 36
Mapping Area C. diphtheria Patogenic & Toxigenic in East Java 2011 -2012
M
M
MM
MM
M
M
MM
MM
M
M+GM+B
M+I
M+BM+B
M+B
M+B
M+B
C difteri var. - Mitis (M)- Gravis (G)- Intermedius (I)- Belfanti (B)
SEBARAN “ C difteriae – Toxigenic “ PADA KLB DIPHTERI DI JATIM s/d 14 Juni
2012
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BKL
BWI
BATM BL
IBL
IMBO
JBD
WGR
EJE
MJO
MKD
RLM
JMA
LMA
LM MOJ
NGJ
PAM
PAS
PON
PRO
PROM SA
M SID SIT
SUM
SBY
TRE
TUB
TAG
BLK0
5
10
15
20
POSITIV RATE SPESIMEN DIFTERI HASIL PEMERIKSAAN LAB. DI JATIM TAHUN 2011
POSITIV RATE (%)
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Year Spec Number
Σ Positive
%
2005 975 32 3.25%
2006 612 1 0,16%
2007 807 35 4,33%
2008 723 39 5,39%
2009 2146 215 10,02%
2010 4866 389 7,99%
2011 3404 154 4.52%
Performance of Diphtheria Laboratory By Outbreak Specimens 2005-2011
0
2
4
6
8
10
12
2005 2006 2007 2008 2009 2010 2011
Positiv rate (%)
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POS. RATE SUSPEK = 63 + 18/ 526 X 100% = 15.4%
POS. RATE TOX = 63 / 526 X 100% = 11.9%
POS. RATE NPC = 18 /526 X 100% = 3.4%
HASIL PEMERIKSAAN BLK TAHUN 2012
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Epidemiological management
to stop transmision dan immunization
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1. Isolasi ketat / barrier nursing: difteri sangat menular
2. Tatalaksana kontak untuk mencegah penyebaran:1. Dewasa: identifikasi sebagai sumber penularan dan obati
bilamana kultur pos
2. anak/saudara:
1. Amati bila dalam masa inkubasi : penderita baru
2. Tanpa gejala, imunisasi lengkap: booster
3. Tanpa gejala, imunisasi tak lengkap/tak imunisasi: imunisasi dasar dan booster
4. Kultur pos: obati
3. Erytromisin etilsuksinat untuk menekan circulating C diphtheria
4. Imunisasi penderita setelah sembuh .
Tatalaksana epidemiologik
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Epidemiology of diphtheria: Prevaccine era
• highly endemic childhood disease in temperate climates– most acquired immunity by 15yrs, few adult cases
• approx. 85% developed immunity from mild or asymptomatic infection, only 15% typical clinical diphtheria
• gradual decline in deaths – was still one of leading causes of childhood death until
widespread vaccination implemented
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Hasil Kultur Tes Schick Tindakan
–++–
––
+, gejala (–)+
Bebas Terapi carrier
ADS + PenisilinToksoid (imunisasi
aktif)
Screening kekebalan dan Tata Laksana
Tes Shick pos berarti anak rentan, negatif anak kebal
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mengapa ada yang tidak kebal
• Sebelum vaccine era transmisi kuman sangat kuat, sehingga dapat menimbulkan kekebalan alamiah
• Transmisi berkurang akibat– Perbaikan sanitasi dan lingkungan hidup– kekebalan manusia akibat vaccine
• Kegagalan imunisasi – Tidak imunisasi– Gagal imunisasi– Cakupan kurang tinggi
• Cakupan SIA (supplementary Immunization Activity) harus tinggi ok – Spill over IgG di tonsil – Membuat kasus menurun
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Prevention and control of diphtheria
• Routine vaccination• Surveillance• Case management• Management of close contacts• Outbreak management• Social interventions
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Diphtheria cases*, deaths, and vaccine coverage England and Wales: 1914 to 2005
0
10000
20000
30000
40000
50000
60000
70000
80000
19141924
19341944
19541964
19741984
19942004
Not
ifica
tions
0
1000
2000
3000
4000
5000
6000
7000
8000
Deaths
Notifications Deaths Coverage 95% coverage
*notifications up to 1985, laboratory confirmed cases 1986 to 2005
Immunisation
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Apa yang perlu dilakukan Ja Tim
• Menekan kematian kasus (short term)– Deteksi dini dan rujukan – Manajemen kasus
• Menekan transmisi & kasus baru (short term)– PE– ORI di daerah kasus
• Mencegah KLB (long term)– Meningkatkan cakupan – Meratakan cakupan, meniadakan kantong
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01 02 03 04 0
< 1 2 4 6 8 1 0 1 2 1 4 1 6 1 8 2 0 2 2 2 4 2 6 2 8 3 0 3 2 3 5 3 7 4 4 5 0 6 0UMUR
JML KASUS DISTRIBUSI UMUR KASUS DIFTERI TAHUN 2010 - 2011 DI JATIM (april)
TH. 2010
TH. 2011
BIAS
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Pilihan Upaya Penanggulangan
Alternatif upaya penanggulangan:
1. Penguatan Imunisasi rutin + Imunisasi tambahan (massal) seperti PIN semua usia + pengobatan kasus + propilaksis terbatas yang diperluas (kontak, guru PAUD, TK, SD, SLP)
2. Penguatan Imunisasi rutin + Imunisasi tambahan terbatas populasi at risk dg usia terbatas + pengobatan kasus + propilaksis terbatas (kontak)
3. Penguatan imunisasi rutin + pengobatan kasus
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upaya penguatan imunisasi
Alternatif :• Penguatan Imunisasi rutin + Imunisasi tambahan minimal
1x (massal) seperti PIN s/d 15 thn • Penguatan Imunisasi rutin secara keseluruhan (semua
kabupaten kota) pada bayi kohort + imunisasi tambahan pada semua usia
• Penguatan imunisasi + Imunisasi tambahan terbatas populasi at risk menurut umur / survei serologik
• Penguatan imunisasi rutin + imunisasi tambahan pada daerah kantong saja
• Catch up immunization di daerah kantong saja
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Vaccination schedule in the UK
• Primary immunisation at 2, 3 and 4 months– diphtheria-tetanus-pertussis-polio-Hib (DTaP/IPV/Hib)
• Booster immunisation at 3½-4 years– (dTaP/IPV or DTaP/IPV)
• School leaving booster at 15 years– tetanus-low dose diphtheria-polio (Td/IPV)
• Opportunistic vaccination with Td/IPV
http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Greenbook/DH_4097254
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JADUAL PEMBERIAN IMUNISASI PADA ANAK SEKOLAH
IMUNISASI ANAK SEKOLAH
PEMBERIAN IMUNISASI
DOSIS
Kelas 1 Campak (Juli/Agust) 0,5 cc
DT (Nop) 0,5 cc
Kelas 2 TT/Td (Nop) 0,5 cc
Kelas 3 TT/Td (Nop) 0,5 cc
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JawaMetode a Timur BAGAIMANA MENGETAHUI ADANYA “ DAERAH KANTONG “ … ?
• Menggunakan indikator • Indikator sederhana dan mudah dipahami• Tidak terlalu banyak indikator• Yang tahu persis petugas setempat• Informasikan secara jujur demi kepentingan “
Bangsa & negara serta anak cucu kita “
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• INDIKATOR SURVEILANSAdanya KLB PD3I di suatu Desa ( 5 th..?)
• INDIKATOR IMUNISASIDesa yang Non UCI (5 th…?)
• INDIKATOR LAIN2X- Adanya informasi penolakan IMM- Adanya desa sulit dijangkau, dll …..
Metode Jawa TimurINDIKATOR UNTUK MENGETAHUI ADANYA “ DAERAH
KANTONG “
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Metode Jawa TimurSELANJUTNYA : APA YG HARUS DI LAKUKAN PADA DESA KANTONG …?
• Cari dusun mana yang masuk kriteria indikator tsb…
• Dilakukan survei ( RCA ) pada 20 Balita tentang status IMM DPT 1 S/D DPT3 …
• Ditanyakan apakah sudah lengkap / sudah di IMMM DPT1 S/D DPT3 ….
• Kalau tidak lengkap / tidak IMM ditanyakan kenapa ….? ( dicari permasalahan secara spesifik dusun tsb )
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Setelah diketahui permasalahannya :
• Lakukan pembahasan bersama (Liprog & Linsek) untuk pemecahan masalah
• Buat kegiatan untuk intervensi pemecahan masalah secara integrasi dan terukur (Mikro planning)
• Persiapkan SDM & Dana
Metode Jawa TimurSELANJUTNYA : APA YG HARUS DI LAKUKAN PADA DESA KANTONG …?
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<1 TH4%
1-3 TH17%
4-7 TH32%
>7 TH37%
TAK DIKET10%
DISTRIBUSI UMUR KASUS DIFTERI TH 2011 DI JATIM
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Bagaimana hasil penanggulangan
DIFTERI yang telah dilakukan
124
2515
30
20
40
60
80
100
120
kasus baru kasus baru di daerah ORI
kasus baru di daerah ORI yg
sudah kena ORI
status > 3x
DAMPAK “ ORI “ TAHUN 2011 - DI JATIM (1 Peb 2012)
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Peta kasus Difteri PKM ARJASA - SITUBONDO 2012
LamonganArjasa
Jatisari Ketoan KD.Dowo
Bayeman
KayumasCurah Tatal
Bondowoso (pkm Cerme)
U
L.Jawa
68
5
15 412
1013 11
3 17
2
116
14
9
7
PKM ASEMBAGUS
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0 0 0 0
1
2
11
2
1
0 0 0 0 0
1
0 0 0 00
2
4
6
8
10
12
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
ORI (2 minggu)
Jml kasus
Minggu ke
- ORI DILAKSANAKAN 2 MINGGU- WAKTU : MINGGU KE 7 s/d 9- SASARAN : SEMUA UMUR- CAKUPAN : 98.6%
SITUASI KLB DIFTERI & PELAKSANAAN ORI DI PUSKESMAS ARJASA KABUPATEN SITUBONDO TAHUN 2012
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SITUASI DIFTERI
JOMBANGS/D 2 JULI 2012
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2
1
18/62
7/118/2
2
32
4
6
1
1
KECAMATAN :1. BANDAR = 22. BARENG = 13. DIWEK = 184. GUDO = 25. JOGOROTO = 76. JOMBANG = 187. KESAMBEN = 28. MEGALUH = 19. MOJOAGUNG = 310. MOJOWARNO = 211. NGORO = 412. NGUSIKAN = 113. PETERONGAN = 614. SUMOBITO = 315. PERAK = 116. KABUH = 1
T O T A L = 72
PENYEBARAN KASUS DIFTERI DI JOMBANG TAHUN 2012 (18 JUNI 2012)
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'00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '120
10
20
30
40
50
60
70
0 0 0 0 0 0 0 0 0 0 0 07
0 0 0 0 0 0 2 1 0 0
13
7
60
TREND KASUS & KEMATIAN DIPHTERI TAHUN 2000 – 2012 (18 JUNI)
DI KAB. JOMBANG
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0%10%20%30%40%50%60%70%80%90%
100%
2011 2012
26
27
>15 TH<15 TH
DISTRIBUSI DIFTERI MENURUT UMUR TAHUN 2011-2012 DI JOMBANG
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RENCANA OPERASIONAL BERANTAS DIFTERI JATIM, 2012 1)
• DASAR PERTIMBANGAN :1. Jumlah kasus dan Insiden Rate2. Ditemukannya Toxigenic C. Dift3. Ditemukan kematian.
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TERIMA KASIH
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MENURUNKAN KESAKITAN- Ketersediaan logistik obat “ Difteri “- Ketersediaan Ruang khusus penderita ( Ruang “Isolasi “ )
- Penggunaan “ APD “ petugas Kesehatan - PENGUATAN IMUNISASI RUTIN & TAMBAHAN- Advokasi kepada SpTHT, Sp Interna, dokter IRD- Advokasi kepada Bupati/Walikota langsung- Optimalkan SBM (Surveilans Berbasis Masy.)
STRATEGI OPERASIONAL 2012
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MENURUNKAN KEMATIAN- Ketersediaan logistik obat “ Difteri “- Ketersediaan Ruang khusus penderita ( Ruang “Isolasi “ )
- Penggunaan “ APD “ petugas Kesehatan - PENGUATAN IMUNISASI RUTIN & TAMBAHAN- Advokasi kepada SpTHT, Sp Interna, dokter IRD- Advokasi kepada Bupati/Walikota langsung- Optimalkan SBM (Surveilans Berbasis Masy.)
STRATEGI OPERASIONAL 2012
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• KEMATIAN MASIH TINGGI
• Penemuan terlambat PETUGAS TAK TAHU• Tak merujuk PETUGAS TAK PEDULI • Nosokomial TAK ADA RUANG ISOLASI• Status imunisasi “D” NEGATIV• Terjadi di daerah sulit WIL.KEPULAUAN• Pengetahuan masy.masih kurang TERLAMBAT
M A S A L A H (2)
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Apa Yang Harus Kita Lakukan ?
1. Menanggulangi KLB2. Menurunkan kasus di daerah endemis tinggi3. Memperkuat imunisasi dan surveilans rutin
Disesuaikan dengan kondisi daerah penanggulangan dan survei/penelitian
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Case: history and examination
• Patient details - name, age, sex- address (school)- hospital & physician
• Laboratory - source / date of specimen• Clinical - symptoms / onset date
- treatment• Epidemiology - immunisation status
- travel history, - animal contacts, raw milk- list of contacts
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Case management I• Antitoxin treatment
– clinical indication– take serum before giving anti-toxin– pre-test for allergy (if time)– dose depends on site, severity of disease
• Isolation– until 2 negative cultures taken 24 hours apart and 24 hours
after end of antibiotic treatment– disinfecting of soiled articles– follow-up cultures 2 weeks after finishing treatment
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Case management II
• Antibiotics (erythromycin or benzylpenicillin)– to eliminate carriage and prevent spread - does not
replace anti-toxin– Nasopharyngeal swabs after treatment
• Immunisation (convalescent stage)– unimmunised: complete primary course– immunised: booster with D (<10 y) or d (>10 y), only
available as part of combined vaccine
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Management of close contacts I
• Anyone in close contact with a case of diphtheria caused by toxigenic C.diphtheriae or C.ulcerans (risk related to duration and closeness of contact)
• Definition of close contacts: – household / kissing contacts/ sekolah??– health care staff (exposed to oro-pharyngeal secretions /
wound discharge of a cutaneous case)
• Domestic pets
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Management of close contacts II
• Throat swabs
• Antibiotic prophylaxis
• Immunisation unless last dose <12 months ago
• Monitor contacts for signs/symptoms of diphtheria for 7 days (self-monitor)
• Inform GP
• Exclude from work if food handler, or in contact with unimmunised children - until screening results known
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Management of close contacts III
• Contacts who are carriers should be isolated and treated until 2 negative cultures from both nose & throat/wound taken 24 hours apart and 24 hours after finishing antibiotic treatment
• Other contacts - public transport, casual contacts - opportunity to consider boosting immunity, depending on level of contact
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KLB Difteri di Cianjur 2001(Desa Cikalong)
1. Hasil pengukuran titer antibodi difteri (Ig G) yang dilakukan terhadap 40 anak yang telah diimunisasi DPT sebagai respon KLB difteri diwilayah desa Cikalong Kabupaten Cianjur tahun 2001 setelah 1 bulan pasca imunisasi, Ig G yang terbentuk memberikan hasil yang kurang memuaskan.
2. Sebanyak 25% anak berumur diatas 5 tahun titer antibodinya nol (0). Angka cakupan imunisasi dasar di Desa Cikalong tersebut menunjukkan lebih dari 95%, selama 5 tahun terakhir.
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Gambar 1. Persentase subyek dengan Titer Serologis
diatas nilai protektfi minimum menurut umur/ kelas
57,9
48,4
34,537,3 35,3
21,2
40,5
72,5 72,567,6
75
33,3
5560 61,5
0
10
20
30
40
50
60
70
80
<1 2 3 4 5 6 SD I SD II SD III SD IV SD V SD VI SMP 1 SMP 2 SMP 3
Umur/Kelas Sekolah
% T
iter
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Gambar 2. Persentasi Subjek dengan Titer Protektif Optimal ( > 0,1 )
19.316.8
5.27.8 7.8
0
36.8
30
20
24.3
17.5
5.1
25
1512.8
0
5
10
15
20
25
30
35
40
<1 1_2 2_3 3_4 4_5 5_6 SD I SD II SD III SD IV SD V SD VI SMP 1 SMP 2 SMP 3
Umur dan Kelas Sekolah
Tite
r Pro
tekt
if O
ptim
al >
0,1
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KLB Difteri di TK Kota Semarang (Sekolah TK) thn 2002
Pemeriksaan titer IgG difteri dilakukan dengan teknik
Enzym Imuno Assay di Puslitbang Dep Kes. dengan cara
Diftolisa G ( bakteri tunggal).
Sebanyak 7,2% anak titer IgG nya nol (0), 92,8% anak
memiliki titer > 0,1 – 1,5 IU/ml.
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KLB di Tasikmalaya & Garut
A. Tasikmalaya, 2005:1. Jumlah penderita 47 orang, 15 orang meningal dan ditemukan 8
orang carrier, (CFR = 31,91%, 2. Umur penderita antara 1 s/d 14 tahun. 3. Lokasi KLB tersebar di 14 desa pada 7 kecamatan.
B. Garut, 2007 :4. Jumlah penderita 11 suspect, 6 confirm, 2 meninggal, (CFR =
11,7 %. 5. Umur penderita antara 2 s/d 14 tahun. 6. Lokasi KLB di 1 desa.
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Upaya yang telah dilakukan di KalTim :• Profilaksis Erytromycin
– Samarinda seberang : 40 org– Lok Bahu : 150 org– Airputih :75 org– Juanda : 60 org– Sempaja : 450 org
• Imunisasi– Umur < 7 th : DT 2 dosis (baru 1 Dosis)
• Di 6 lokasi KLB sebanyak 3000 sasaran (Puskesmas Segiri, Juanda, Lempake, Air Putih, Bengkuring, Sempaja).
– Umur 7 – 15 th : dT• Di 6 Lokasi KLB 3.515 sasaran.
Sumber: Dinkes Kaltim
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Diphtheria: a review
ismoedijanto
Pertemuan 09 11 2011
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•Mengapa Difteri menular dan berhasil dilaporkan?
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Faktor Penyebab (bag.1)
1. Sifat penyakit Difteri yang sangat mudah menular melalui droplet atau udara
2. Adanya karier yang potensial menularkan Difteri sampai 6 bulan bila tidak terdeteksi dan belum mendapat obat profilaksis
3. Program imunisasi rutin pada bayi dan anak sekolah saat BIAS (Bulan Imunisasi Anak Sekolah) dengan cakupan per Kabupaten/Kota tinggi tetapi kenyataan di lapangan tidak merata di tingkat Kecamatan, Kelurahan/Desa
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Faktor Penyebab (bag.2)
4. Penanggulangan setiap ada kasus Difteri tidak maksimal terutama dalam pemberian obat profilaksis yang luas tanpa pengawasan minum obat sampai tuntas. Kegagalan ini dikarenakan faktor efek samping obat profilaksis (erythromicin), sementara pasien/keluarga tidak merasa sakit.
5. Sosialisasi kepada semua tenaga kesehatan dan masyarakat tentang penyakit Difteri belum merata, sehingga kesadaran dan peran dalam kewaspadaan maupun penanggulangan terhadap Difteri masih belum optimal.
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Faktor Penyebab (bag.3)
6. Ada pergeseran epidemiologi dimana Difteri sebelumnya banyak menyerang anak balita dan anak sekolah 7 – 14 tahun, pada beberapa daerah mulai bergeser menyerang orang dewasa ( usia > 15 tahun)
7. Ada keterbukaan dan upaya yang sungguh-sungguh dalam penanggulangan kasus Difteri oleh Dinas Kesehatan Kabupaten/Kota yang didukung kerjasama dengan Dinkes Prov dan para Ahli di RS Dr. Soetomo, instansi Pusat di Daerah maupun dari Pusat/WHO serta dukungan laboratorium terutama dari BBLK Sby
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pseudomembran tebal menyumbat jalan nafas
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Immunity to diphtheria in adultsPercent of sera with antitoxin => 0.1 IU/ml
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Evaluasi Operasional
1. Evaluasi program short term : evaluasi proses dan output Penurunan kasus Penyediaan fasilitas, obat, rujukan Cakupan imunisasi respon KLB Kualitas imunisasi respon KLB Evaluasi (pengukuran titer IgG) pasca respon KLB (ORI) Pengawasan minum obat (propilaksis) bagi kontak Evaluasi transmisi pasca profilaksis
2. Evaluasi program longterm: evaluasi routine dan supplementary immunization Cakupan imunisasi rutin Invalid dosages Cakupan booster Cakupan BIAS Cakupan sweeping dan backlog fighting Cakupan supplementary
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Year Spec Number Σ Positive Percentage2005 975 32 3.25%
2006 612 1 0.16%
2007 807 35 4.33%
2008 723 39 5.39%
2009 2146 215 10.02%
2010 4866 389 7.99%
2011 8012 519 6,4%
2012 20.0%
Performance of Diphtheria Laboratory Close Contact Specimens (Old Algorithm)
2005-2011
95
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Masalah MutuRekap Hsl Supervisi Suportif
• UPS penyimpanan vaksin tdk memenuhi syarat cenderung beku
Penyebab : 1. LE tdk distandarisasi (RT, BOX)
2. Krg pengawasan & pembinaan dari Puskesmas & kab/kota
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Masalah CakupanRekapan Hsl Coverage survey
Masy menolak, dg alasan :• Situasi
Anak tak dibawa ke tempat pelayanan krn sedang sakit = 30%. Orang tua terlalu sibuk = 13% Anak hadir tetapi dalam keadaan sakit = 9% Kurangnya vaksin = 9%. Biaya tidak terjangkau (transport menuju tempat pelayanan) = 6% Tempat pelayanan imunisasi terlalu jauh = 6%. Jadwal posyandu yg tak sesuai dgn waktu luang orang tua = 4%.
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Masalah CakupanRekapan Hsl Coverage survey
Masy menolak, dg alasan :• Kurang Informasi
– Kurangnya pengetahuan ibu tentang kebutuhan imunisasi = 20%.
– Kurangnya pengetahuan ibu tentang kelengkapan imunisasi bagi bayinya = 13%.
– Takut efek samping = 13%– Kurangnya pengetahuan ibu tentang jadwal pelayanan
imunisasi di Posyandu/Puskesmas = 20%.– Presepsi yang salah tentang kontraindikasi = 3%
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Masalah CakupanRekapan Hsl Coverage survey
Masy menolak, dg alasan :• Motivasi
Penundaan imunisasi = 12%.Kurang percaya ttg manfaat imunisasi = 4%.Adanya rumor yang buruk tentang
imunisasi/vaksin = 3%.
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Masalah MutuRekap Hsl Supervisi Suportif
• Puskesmas & Posyandu krg patuh thdp SOP (umur minimal DPT-HB1 & Campak, interval min dosis berikutnya).
Penyebab : 1. Ptgs m’vaksinasi berdasarkan jadwal Posyandu, bukan tgl lahir bayi.
2. Bayang-bayang target K-4, Kn1 dll record di kohort bayi tdk sama dg di buku KIA / KMS (tgl lahir, tgl imunisasi)
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HASIL ASSESMENT KUALITAS PELAYANAN “ IMM SWASTA “ (UPS)
DI 9 KOTA DI JATIM (2009)
• 56.3% LE belum distandarisasi• 40.6% LE digunakan menyimpan barang selain
vaksin• 40.6% LE tak dilengkapi termometer (ada tapi
tak berfungsi)• 34.4% LE suhunya tidak memenuhi syarat 2-8%
• 50% Vaksin belum ditoto sesuai sifat vaksin• 18.8% Vaksin dengan VVM CD masih disimpan• 15.5% Vaksin kadaluwarso masih disimpan• 9.4% Vaksin ditemukan kondisi beku• 68.3% Vaksin sisa tak dilengkapi tanggal buka
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HASIL ASSESMENT KUALITAS PELAYANAN “ IMM SWASTA “ (UPS)
DI 9 KOTA DI JATIM (2009)
• 56.3% Pelarut vaksin belum disimpan di LE minimum 12 jam• 21.9%Petugas belum tahu penyebab vaksin
rusak• 37.5%Petugas belum tahu tanda2 vaksin
rusak• 43.8%Petugas belum tahu jenis vaksin
berdasarkan sifatnya• 50% Petugas belum tahu batas waktu
maksimum penyimpanan vaksin SISA• 37.5% Petugas yg membersihkan lokasi
suntikan dengan alkohol