ACKNOWLEDGMENT

With thanks to Allah SWT, the tutorial booklet for Block 18 can be completed. The book is expected to be a guideline for the implementation of the learning and tutorials on Competency Based Curriculum (CBC) at the Medical Faculty University of Riau. Compilers expect this book can be harnessed and perfected continually, because the input and advices from teaching colleagues for this book is highly needed. Thanks to sources, contributors, collaborators, and all parties involved in the preparation of this book. Hopefully the presence of this book can be useful for education and teaching process in Medical Faculty University of Riau. Pekanbaru, 20th May 2013

compiler

Red Spot Dr boyke is a new doctor in Puskemas Dusun Merbau. He has already been there for a few days. One day, when he walked to house of citizen for giving presentation about 3M plus, he saw pile of rubbish at the front of citizens house and pool of water in everywhere. There are so many kids playing around the house. They didnt use shirt or singlet and sandals. Dr. Boyke approached to a woman who took water in water storage beside the well and then dr. Boyke introduced his self as a new doctor in the village. The woman told that in their village there are so many kids got a fever and red spot in their body. Moreover the womans child is dead 3 months ago. Her child got continious fever in 5 days and appeared many red spot in his body, and finally her children unconcious. When she brought his child to the Puskemas, his child has already dead. These incidents have been occured in the last six months. Every years in a rainy season, this disease increased significantly. What actions should be done by dr.Boyke? 1. Terminology - Counseling - 3 M plus - Fever - Red Spot

2. Learning issues: - Criteria of healthy environment - Risk factor for disease ( behavior and environment) - Vector and vector borne disease control - Control of Environmentally based disease ( Dengue hemorrhagic fever) - Epidemic investigation/ Extraordinary condition and surveillance

I. Criteria of healthy environment 1. Clean air ( contain oxygen, there are many trees or plants) 2. Clean water ( drinkable, can used for cooking, or taking bath, etc) 3. Clean river or clean ditch ( fish can live there) II. Risk factor for disease Jhon Gordon explain in epidemiology models of spread of infectious diseases that transmission of dengue hemorrhagic fever (DHF) can be influenced by interaction between three factors: 1. Host factor : the host factor in this context is a person who vulnerable get dengue hemorrhagic fever 2. Vector borne disease and agent ( etiology of disease) factor : virus DEN type 1-4 as a agent of dengue hemorrhagic fever and mosquitos (Aedes aegypti and Aedes albopictus) as a vector borne disease of DHF 3. Environment factor : environment factor which cause contact transmission DHF easily.

Any attempt to break the chain of disease transmission can be done through modifying involved factors, but the important things are community understanding, awareness, manner and behavior changing towards DHF disease will support it. DHF disease will be a health problem forever, if our approach to this problem just a reactive ways, such as stamp out the fire after conflagration. Preventive ways is really needed, with create and guard environment sanitation everytime. It will keep community health status in the best condition all the time.

III. Vector control DHF disease is one of community health problem in Indonesia. It always evoke extraordinary event with many people suddenly dead. The important vector borne of DHF disease in Indonesia are Aedes aegypti, Aedes albopictus and Aedes scutellaris, but the main vector is Aedes aegypti. DHF disease is the infectious disease caused by Dengue virus which is transmitted by mosquitos (Aedes) bite. It has signs and symptoms such are fever, bleeding manifestation and

potential cause shock and dead. Vaccine or medicine for DHF disease until now haven't been found yet. So the best way to prevent it is break the chain of transmission with control vector borne disease. The main vector borne of DHF disease in Indonesia is Aedes aegypti and its morphology are: The adult female Aedes aegypti has body with blackish-brown colours. The length of their body is 3-4 cm, with disregard their feet. Their body and foot are covered by shell with silverywhite line. On the dorsal (back) side appeared 2 vertical curved line (at the right and left side) which will be a characteristic this species. Scale on mosquitos body are easily deciduous so it will complicate identification process to old mosquito. Mosquitos size and colour can be differ between population, its depend on environment condition and nutrition. The adult male Aedes aegypti has body smaller than female and it has thick hair on antenna of adult male Aedes aegypti. We can find it with bare eyes. The life cycle of Aedes aegypti Mosquito Like another mosquito, Aedes aegypti lays their eggs on the surface of clean water individually. Every day female Aedes aegypti can lays 100 eggs/day. The egg is oval, black in color, and separated each other. The egg hatch in one or two days. There are four phases in the development of the larvae which called instar. The development from an instar to the fourth instar takes about five days, until it reaches the fourth instar, the larvae turns to be a pupa whereas it entering the dormant phase. (inactive, sleep). Pupa can survive in two days until it turns become adult mosquito. The development from egg until becoming an adult mosquito takes about seven until eight days, but can be much longer if the environment didnt fit enough. Aedes aegyptis egg can survive in a dry condition, in fact it can survive until one month. If its drown in water, the dry egg can hatch into larvae. In contrary, the larvae is depend on enough water provided for its development. The condition of larvae affects the condition of adult mosquito produced. Aedes aegypti activity pattern This type of mosquito is diurnal, which is very active in the morning until afternoon. The transmission of this disease is carried by female mosquito, because only female mosquito can sucks blood. This is because the female mosquito needs the protein, which is prostaglandin, to breed an egg. The male mosquito doesnt need blood and get source of energy from flowers pollen. Aedes agypti mosquito likes a dark area and black or red things. This disease commonly strikes children. The virus infection in mosquitos body can affects change of behavior which leads to increasing of viral compentention, which is the ability to spread the viral infection. Dengue viral

infection can make the mosquito difficult to sucks the blood, so that it must pierce the skin several times. This makes the mosquito unable to sucks blood, so the mosquito moved to other people. In consequence, the transmission of DHF is greater. In Indonesia, the Aedes aegypti mosquitos breeding nest is commonly at residential environment , where there are many water reservoirs in the tub or jar. Environmental factors : a vector of dengue fever is usually known lay its egg in the puddle contained in the remains of tin cans , water reservoirs , bath , old tires and etc. The number of patients with DHF commonly increased at the beginning of the rainy season. In densely urban areas , the peak numbers of DHF patients coincided with the beginning of the dry season. Thus, public awareness of environmental cleanliness , burying the rest of the junk and keep the clean water reservoirs remain closed are several effective efforts to reduce the rate of transmission of dengue disease. IV. How to prevent and control of DHF environmental based disease To eradicate dengue fever and dengue hemorrhagic fever, there are several things to be concerned : 1. 2. 3. 4. 5. Ways to prevent Patient, contacts and environment monitoring. Epidemic. Disastrous implications International action

Prevention Method 1. Counseling and provision of information to the public in protecting themselves against mosquito bites ( wire gauze , long clothing , repellent ) and cleaning mosquito breeding places. 2. Conducting a survey in the community to determine the level of density vector , the mosquito breeding places , and larval habitats . Aedes aegypti larval habitats are artificial water reservoirs or natural near settlements ( old tires , flower vases , bath) 3. Manufacture of mosquito nest eradication plan and its implementation. Epidemic 1. Aedes species annihilation in the residential neighborhood , cleaning the breeding places , sowing larvicides in all places as a potential breeding places of Aedes larvae. . 2 . The use of mosquito repellent for people who vulnerably exposed to mosquitoes

Disastrous Implication Plague or an extraordinary events can be so intense attacking most of civilian in some places. International action The Aplication of international agreement had been made to prevent spreading of aedes aegypti through aeroplane, ships, and ground transportation from endemic place to other places. The action are upgrading the international surveillance and exchange information between countries using the WHO cooperation center. Surveillance of patients, contact, and environment 1. Reporting to the local health center. An official case report is compulsory if there is an extraordinary events occur. 2. The patiens have to be isolated, and beware of any blood. The patient has to be prevented from mosquito bites in the afternoon with using the mosquito net, mosquito net with insecticide, or insecticide spray in the treatment room until the fever is gone. 3. Simultaneously disinfection is not performed 4. Quarantine is not performed 5. Contact immunization is not performed. The yellow fever immunization will be performed if the dengue fever occur in yellow fever focus area. This is because both disease are caused by the same vector. 6. Contact and source of infection investigation. Investigate the residence of patients 2 weeks before illness, as well as searching for other sick people who is unreported or undiagnosed. 7. Supportively adequate treatment. There is no specific treatment for dengue fever and dengue hemorrhagic fever.

Fogging Definition Fumigation / fogging is to use anti-mosquito machines / tools and special insecticide at the time and in a certain area with a well-trained person. This procedure are such as fumigation / fogging or focused fumigation / mass fogging (Blitar Mayor Regulation No. 35 of 2011). Fumigation / focused fogging is the eradication of dengue mosquito by fumigation focused on the area where there are a suspects or positive DHF patients. Fumigation / mass fogging is fogging activities simultaneously and thoroughly in the event of an outbreak of dengue fever. Fogging with insecticide will be conducted if there is a positive results of epidemiological investigations, wich are : there is a DHF patients / suspects, 3 or more people discovered had fever for no apparent reason and the discovery of larvae. Focused fogging Target is calculated based on the amount of focus area will be addressed (1 focus = 300 homes or 15 hectares) within 1 year. This activity is carried out by clinic staff or in collaboration with the district health office / town. Sprayers are clinic staff officer or officers trained casual. The purpose of fogging The purpose of fogging is to kill most infectious vectors rapidly , so that the chain of transmission can be disconnected immediately . Besides that, these activities also aim to reduce vector density for a sufficient time in which the carriers of the virus to grow on its own . Meanwhile, according to MOH (2007 ) in Riyanti , Ervina (2008 ) , fogging is one of vector control which aimed at preventing the outbreak with breaking the chain of transmission in the location of dengue cases , namely in the DHF patient / suspect houses and surrounding locations which are expected to be source of infection. According to WHO recommendations, fogging basically only been done in areas where mosquito-based disease cases are found , first : Found patients or suspected patients of Dengue Hemorrhagic Fever ( DHF ) , with the purpose of transmission of the disease through mosquito Aides aegypti can be stopped. The explanation is that if a person was found suffering from dengue fever or dengue suspect it means that ones blood flow has dengue virus or virus that causes the disease , and subsequently if he/she was bitten by a Aides aegypti mosquito, the mosquito is declared as a carrier virus ( vector ) , if it is not killed immediately by spraying, it may provide opportunities for the mosquitoes to flies and bites ( transmit ) the virus to others around them within a radius of about 100 meters.

Second : At the beginning of the season where the Aides aegypti mosquito breed with preliminary epidemiological investigation has been done or the results of the survey showed larva Free Flick < 95 % , it means that from 100 houses , larvae-free houses are below 95 , therefore, fogging can be perfomed. Mosquitoes usually will develop rapidly in the early of rainy season , which means the mosquito population in an area will be more and more . Epidemiological investigation about mosquito-based disease should be conducted by looking the pattern of malaria, dengue , chikungunya and filariasis , if there is a tendency of sick people increasing at that time or at a specific time and place after the larva survey found that Flick -Free Numbers < 95 % From those two WHO recommendations , in principle and substance, fogging can be conducted if there are cases found ( dengue , malaria , chikungunya , and filariasis ) recently. The types of fogging According to WHO (2001), in general, there are two forms of fogging / fumigation area used in the control program Ae. Aegypti, which is "FOGS thermal / thermal fogging (fumigation with hot steam) and" cold FOGS / cold fogging "(fumigation with cold vapor). Both of these techniques can be done with a machine that operated on the vehicle or by hand. On thermal fogging (fumigation with hot steam), liquid insecticides used and is usually dissolved in a solvent with additional oil emulsifiers. The advantages of thermal fogging applications include visible smoke generated so that the range can be observed as well as spreading the low concentration of the solution. While the lack of thermal fogging application, among other things: smelly and oily spotting / slick, expensive to purchase, fire, and highway traffic hazards when fogging conducted on the highway and near the highway. Cold fogging (fumigation with cold vapor) system known as the ULV (Ultra Low Volume), droplets generated in this application does not involve heat energy, but uses kinetic energy. ULV several advantages such as less air pollution, reduce the danger to other biotic / non targets, there is no interference with the bustle of the city as well as operating and materials costs relatively less dangerous (efficient).

Fogging procedures 1. Fogging operations planning a. Creating a map / sketch of the areas to be sprayed. b. Stacking energy needs preparation tools implementers. c. Preparation completeness officer d. Preparing the insecticide. e. Check the condition of fog machines. f. Calculate the operational costs. g. Calculate the length of operations. h. Daily implementation schedule.

2. Target preparation Prior to the implementation of fogging, the information must be submitted to the population WHO, 2001): a. Spraying time, eg 06.30 till 10.00. b. All doors and windows should be opened. c. Plates, food, fish ponds, and bird cages must be covered. d. Stay away from doors and windows during spraying, or temporarily leave home and / or sprayed area until spraying is completed. e. Children or adults do not follow the team sprayers from house to house.

3. Preparation tools and materials a. fogging equipment The tools are consist of a portable thermal fogging machine fog system (heat) or ultra low volume sprayer mounted (cold system). Spraying machine according to how to operate it are classified into: machine with manual starter pumps and pumps that use electric starter.

c. Preparation of tools and materials:

1) Mix the ingredients (diesel and insecticides). By the WHO drug standard for fogging, 1 liter drug is used for 15 liters of diesel, with a radius of 200 meters. 2) Stir the mixture until homogeneous. 3) Pour mixture into the fog tank. 4) Fill the fuel into the premium tank of the fog machine. 5) Start the engine, wait until the sound of the machine is stable. 5. Fogging process with portable steam sprayers a. Steam fumigation using the portable hot steam sprayer carried from house to house, always do from the direction of the wind and then the wind hit . b. All doors and windows must be closed for about a half hour after fumigation to ensure a good penetration of the smoke and maximum destruction of the target mosquitoes . c. For the one storey house, fumigation can be done from the front door or opened windows without entering any room in the house . All bedroom doors should be opened to allow the smoke to spread throughout the house . d. For multistories house, fumigation is done from the top floor to the bottom floor , and from the back of the building towards the front . This is done to ensure that the fumigation officer has a clear vision along the lines that he spray . e . If fogging is done outside the home, it is necessary to direct the smoke to all places that have the potentiality to be a place of rest, including fences, closed channels, the bushes, and the shade ( under a tree ) . f . The most effective type of steam used to control the mosquitoes is dry steam type which is only moisturize your hands when they flicked through the steam within 2.5 to 3 meters in front of the steam tube. Adjust the steam setting in order to oily droplets on the floor and the furniture can be reduced . After the fumigation , the door is closed and all residents remained outside until 30 minutes -

1 hour. According to WHO (2001), to optimize fumigation conditions ,that needs to be considered include : 1. In the morning ( 6:30 to 8:30 ) and afternoon temperatures are usually quite chilly. Because of the cold weather, it is more comfortable for workers wearing protective clothing. In addition, these hours are the most active time of adult Ae . Aegypti 2. At noon , when the temperature is high , the heat conduction of the soil will inhibit the spray concentration to approach the land where the adult mosquitoes perch so that the implementation of spraying become ineffective . 3. Maximum wind speeds between 3 and 13 km / h allow the spray to move slowly and stay on top of the ground so that the mosquitoes can get the maximum exposure. Air movement which is less than 3 km / h can cause vertical mixing , while the air speed above 13 km / h causing sprays spread too quickly 4. Spraying should not downwind , because the smoke will turn on the officers and spraying become ineffective. 5. When heavy rain , the spreaded spray would lose the consistency and effectiveness. If the rain is torrential , spraying must be stopped and the head of the spray machine should be directed downwards to prevent the water enter the blower . 6. Spraying can be done when the drizzle . In addition , mosquito activity increases when humidity reaches 90 , especially when the drizzling rainNegative impacts that may result from the fogging are : Impact of fogging 1 .Many pollutants resulted by the machine because of the insecticide and incomplete combustion. 2 . Pollutants that contaminate food , drinking water and the environment after the fumigation can damage the health of people either directly or indirectly. Therefore people are encouraged to seal food , drinking water , bathing water , plates , cups , spoons , etc. . In this case not all people do so, even when fogging is still done, a lot of people do not want to leave the house, there are children who follow the workers and there are people enter the house before the smoke dissapear.

3 . Fogging require considerable expense ( Rp . 1,900,000 for radius of 200 meters ), a force and trained ( not efficient). While its killing power only 1-2 days , after that the number of mosquitoes will increase and will transmit dengue easier. 4 . In generally, fumigation gives the false satisfaction to people, they feel safe and do not do PSN ( mosquito nest eradication ) again. Sometimes in the location where fumigation just done, new cases of DHF arise and the number of mosquitoes increase . 5 . Fumigation is not a prevention way of DHF but the way to break the chain of transmission has when DHF occurred. The feature of the dengue infection presence is there are more than one DHF patients in the radius of 200 meters within a week. In this case people often assume that the fogging done after waiting for more victims . V. Outbreak investigation / Extraordinary Events ( KLB ) . When there is an Extraordinary Incident ( KLB ) or " outbreak " of certain diseases such as dengue fever in an urban area, we can look it as a process of viral breeding in the pond of giant culture media called " city dwellers ". The population of the urban area, can be analogous to a culture medium for the virus that causes the outbreak. Virus will breed freely , moving from a person ( Culture media components ) to another ( other culture media components ) that do not have immunity. The ongoing process will reach its peak , and then decreases because of the improvement of immune system in these subpopulations, or perhaps members of the population has decreased since passed aways, and resulting food supplies for the virus is running low. If this events depicted to the graph of growth, the graph is initially increased, reached the peak, then declined and eventually run out of food media. Basically when "plague" or KLB left , will peak and then decline because of the natural immunity. Or no longer effective culture media because they died or the left population is a formidable population. To prevent the outbreak of human or nature can intervene in order to decreasing the graph occur rapidly Epidemic Infectious Diseases by the definition is an incidence of infectious disease outbreak in the community that significantly exceeds the number of patients the number of patients than the circumstances prevalent at the time and a particular region and can cause harm ( Act 4 of 1984 , Chapter I , Article 1 ) and the head of the region aware of the outbreaks incidence in the region works and immediately take the action ( act 4 of 1984 , Chapter VI , Article 12, Paragraph 1 ) , then the activity should be reported to the Ministry of Health in stages.

PP 40.1991 . Chapter I. Article 1 Paragraph 7 : Outbreak is the onset or increased incidence of morbidity / mortality in the epidemiological significance of an area within a certain time , and is a condition can lead to an outbreak . Responsible for the operational implementation of outbreak response is the Regent / Mayor, while in charge of the technical is the city health districts. In the event that an outbreak occurs more than one work area, the response is coordinated by the governor . While the setting of infectious disease outbreaks and revoke such designation is Minister ( Act 4 of 1984 of Article 4, paragraph 1 and 2 and PP. 40.1991 chapters 2 to 5 ) .