Communicable Disease, Natural Disease, Surveillance Control and Outbreak Investigation

Jontari Field Epidemiology Training Program (FETP)

Brief outline

1. 2. 3. 4. 5.

Communicable disease and NCD Surveillance Natural Diseases Outbreak Investigation Indeks case (First case)

Communicable Disease (Source: CDC, 2010)

An infectious disease TRANSMISSIBLE (as from person to person) by DIRECT CONTACT with an affected individual or the individual's discharges or by INDIRECT MEANS (as by a vector)compare contagious.

35 000 000 people died from chronic diseases in 2005 (WHO, 2005)

Estimated deaths by cause, India, 2005 Source: WHO, 2007

Global Burden of Disease 2004

Leading Causes of Death in Developed Region, 1990 (in thousands)

Deseases Number Percent

Ischemic heart disease

Cerebrovascular disease Trachea, bronchus, and lung cancers Lower respiratory infections Chronic obstructive pulmonary disease Colon and rectum cancers Stomach cancer Road traffic accidents Selfinflicted injuries Diabetes mellitus

2.695 1.427 523 385 324 277 241 222 193 176

24.7 13.1 4.8 3.5 3 2.5 2.2 2 1.8 1.6

Leading Causes of Death in Developing Region, 1990 (in thousands)

Deseases Number Percent

Lower respiratory infections Ischemic heart disease Cerebrovascular disease Diarrheal diseases Conditions during the perinatal period Tuberculosis Chronic obstructive pulmonary disease Measles Malaria Road traffic accidents

3.915 3.565 2.954 2.940 2.361 1.922 1.887 1.058 856 777

9.9 9 7.5 7.4 6 4.9 4.8 2.7 2.2 2

Chronic Disease Is Not Only The Disease Of Wealthy Nations

WHO, Preventing Chronic Disease A Vital Investment, 2005

Masalah Kesehatan di Masyarakat Indonesia (Triple burden)

New emerging disease (H1N1 & SARS) Masa sekarang terjadi transisi epidemiologi: NCD dan CDC (pola hidup)
Masa lalu muncul kembali Penyakit Infeksi (TB, Malaria, Polio & Campak)

Chronic diseases are being neglected in the MDG (year 2000)

Triangle Epidemiology

KONSEP PENYEBAB & PROSES TERJADINYA PENYAKIT

Proses kejadian suatu penyakit krn adanya proses interaksi antara Manusia (HOST), Penyebab (AGENT) serta lingkungan (ENVIROMENT) lebih sesuai dengan penyakit INFEKSI

HOW IS THE RELATION SHIP

Sehat seimbang antara host, agent, enviroment

E H A E A H E
Sakit perubahan menurunnya daya tahan tubuh Sakit perubahan lingkungan yang mempermudah penyebaran agent . Ex. Akibat banjir

Epidemiologic triangle
Is comprised of HOST, AGENT and ENVIRONMENT. 1. A host: is a living organism capable of becoming infected. 2. An agent: is a factor that must be present (potential missing) for the occurrence of a disease. 3. An environment: extrinsic force of situation affecting the hosts opportunity to be exposed to an agent.

List some of the components affecting disease

Host Characteristics
1. Age 2. Genetics 3. Sex 4. Socio economic 5. Immunity

Agent Characteristics
1. Environ. stability 2. Virulence 3. Resistance
(over prescription AB, mutation, survival)

Environment Characteristics
1.Biologic (vectors & Reservoirs). 2. Physical (heat & pop. density) 3. Social (culture)

4. Infectivity 5. Pathogenicity

Transmisi

NATURAL HISTORY OF DISEASE

NATURAL HISTORY OF DISEASE

Preclinical Phase Clinical Phase

Biological onset

Symptom

Diagnosis

Therapy

Biological Onset

Lead time Detectable by screening

NATURAL HISTORY OF DISEASE

Preclinical Phase Clinical Phase

Biological onset

Promkes Screening (sadari)

Symptom

Nausea Fever

Diagnosis

Therapy

Sehat Sakit Cacat Mati

Tk. Pencegahan I
Promkes Immunisasi

Tk. Pencegahan II
1.Penemuan dini. 2. Pengobatan segera Pembatasan Ketidak mampuan

Tk. Pencegahan III

REHABILITASI

Exposure:
1.With no know risk factors. 2.With disease susceptibility

Natural history of disease

Onset of symptoms Usual time of diagnosis

Pathologic changes

Stage I: Susceptibility

Stage II:
Sub-clinical disease

Stage III: Clinical disease

Stage IV: 1.Recovery 2.Disability

3. Death
PRIMARY PREVENTION:
1. Health promotion

SECOND PREVENTION:
1. Case finding 2. Medical care 3. Disability limitation

TERTIARY PREVENTION: 1.Rehabilitation 2.Social disability

2. Screening
3. Imunization

Stage I (Pre-Disease)
Level I 1. With no risk factors 1. 2. 3. 4. Healthy change Lifestyle Nutrition Environment. Description

1. With disease susceptibility

1 Nutritional supplement 2 Immunization 3 Occupational & Vehicle safety Risk factors which assist (Un-modifiable risk factors & modifiable risk factors the development of disease exist, but disease has not developed. 1 2 3 4 5 Smoking. Overweight. Cholesterol. Health Promotion. Protection

2. Description

1. Example

McDonalization

Natural History Of Disease

Herd immunity concept

Stage II (Symptomatic Disease)

Level II
1. Pre-symptomatic disease

Description
1. Should be focus on screening 2. Case finding 3. Medical care (if disease found)
Changes have occurred to lead toward illness but disease is not yet clinically detectable.

2. Description

3. Example

1 Atherosclerotic changes 2 Alveoli deteriorate (Cancer/TBC)

Atherosclerosis Timeline Stage II (Symptomatic Disease)

Foam Cells Fatty Streak Intermediate Atheroma Lesion Fibrous Complicated Plaque Lesion/Rupture

Endothelial dysfunction
From first decade From third decade From fourth decade
Smooth muscle and collagen Thrombosis, haematoma

Growth mainly by lipid accumulation

Adapted from Stary HC et al. Circulation 1995;92:1355-1374.

Stage III (Clinical Disease)

Level III
1. Clinical Disease

Description
1. Focus on disability limitation 2. Medical and surgical treatment 3. Limit damage from the disease Focus on Medication: 1 Medical rehabilitation 2 Social rehabilitation Detectable signs and/or symptoms of disease exist: 1 Recognizable signs and symptoms divided based on morphological alteration, functional limitation. 2 objective assessment. 3 epidemiological study purpose. 1. Emphysema detected by pulmonary function. 2. Mamae Ca 3. Cervic Ca

2. Tertiary

1. Description

1. Example:

Morphological Alteration
Ex. TNM Classification for breast cancer STAGE Tumor Nodes Metastasis I < 2 cm (-) (-) II 2 5 cm (-)/same side (-) III > 5 cm (+) same side (-) IV any side any nodes (+) 5 years survival : 90% -65% -45% -10%

Stage IV (Disability)
Level IV
1. Disability

Description
Focus on rehabilitation Disease has progressed to the point of causing a residual effect. Outcome of disease: 1. Recover 2. Death 3. Disease controlled with disability 4. Disease controlled without disability 5. Variable individual reaction to physical impairment, Chronic disability become SOCIETY BURDEN (Stroke)

1. Description 1. Example

Mode of Transmission

RESERVOAR

Chain of infection (mode of transmission) (from principal of epidemiologi, 2nd ed, US, CDC)

Suspectible Host

1. 2. 3. 4. 5.

Droplet Airborne Direct contact Vector Vehicle

1. Direct 2. In-dIrect

AGENT

Portal of Entry (penular)

1. Reservoir: Habitat alamiah dari sebuah agent yg infeksius (manusia, binatang, sumber lingkungan).
2. Sumber infeksi: Orang atau objek yg tempat asal agent yg menginfeksi penjamu. 3. Carrier: Seseorang yg terinfeksi namun tidak menunjukkan gejala penyakit secara klinis (HIV; tergantung kpd pekerjaan, eq: pramugara, pembuat burger). 1. Transmisi: Penghubung dalam rantai infeksi (berguna u pencegahan, eq: ventilasi, kawat nyamuk, dll)
a) Langsung/Direct: sentuhan, ciuman, hubungan kelamin, droplet, bersin, batuk, transfusi darah, injeksi, menyusui, transpalsental.

b) Tidak langsung/In-direct: Makanan, minuman, vektor, dll

Direct and indirect transmission

1. Direct transmission: is the transfer of an infectious agent by physical contact with; lesions, blood, saliva or other secretion (direct aerosolization). 2. Indirect transmission: occurs when the infectious agent spends a variable period within or upon some intermediary substance or living organism. How about Hepatitis A (fecal-oral route) Eq: Penjual burger. 1 Health practitioner always cover mouth when you cough 2 Wash hands after wards

Tujuan sistem kewaspadaan dini Dan Outbreak Investigation

Laporan Penyakit Menular DBD

250

200 Jumlah kasus

1. Musim 2. Cuaca

150

100

Masa pencegahan (PSN)

min max 2010

50

0 jan feb mar apr may jun jul aug sep oct nov dec

Gambaran Kasus Diare Pada Beberapa Kecamatan Kab.Agam, SUMBAR (Januari, 2010)

Definisi KLB (Kejadian Luar Biasa)

Outbreak is simply a higher frequency of disease or injury than is expected for a typical population and time period. Adalah timbulnya suatu kejadian kesakitan/kematian dan atau meningkatnya suatu kejadian kesakitan/kematian yang bermakna secara epidemiologis pada suatu kelompok penduduk dalam kurun waktu tertentu (Undangundang Wabah, 1969). Pada penyakit yang lama tidak muncul atau baru pertama kali muncul disuatu daerah (non-endemis).

Definisi Wabah
Wabah adalah kejadian yang melebihi keadaan biasa, pada satu/sekelompok masyarakat tertentu (MacMahon and Pugh, 1970; Last, 1983, Benenson, 1990). Peningkatan frekuensi penderita penyakit, pada populasi tertentu, pada tempat dan musim atau tahun yang sama (Last, 1983).

Perbedaan wabah dengan KLB:

1 Wabah harus mencakup jumlah kasus yang besar. 2 Daerah yang luas. 3 Waktu yang lebih lama. 4 Dampak yang timbulkan lebih berat.

The difference between epidemic, endemic and pandemic

1. Epidemic: That each infected person is infecting multiple other individuals, so the number of infected persons is growing exponentially (other words each infected person is rapidly) Out break 2. Endemic: The disease that always present, to a greater or lesser extent geographic location 3. Pandemic: is an epidemic that is widespread over a large area or all of a geographic area.

How do we detect outbreaks?

Sources:
1. 2. 3. 4. 5. Surveillance data. Medical Practitioner. Affected persons/groups. Concerned citizens. Media

Jumlah Kasus Diare Mingguan Menurut Desa di Pusk. Cawas II, Kab. Klaten, Jateng Tahun 2011

Data penderita Diabetes Melitus di DIY (20062010)

1200 1000 800

Kota

600 400
200 0

Bantul
Kl.Progo Gn. Kidul Sleman

2006

2007

2008

2009

2010

Why Investigate Outbreaks?

1. 2. 3. 4. 5. 6. Control and prevention. Severity and risk to others. Research opportunities. Training opportunities. Program considerations. Public, political, or legal concerns.

Control and Prevention

Skala Prioritas Dalam Melakukan Investigasi dan Penanggulangan (Control) Wabah Berdasarkan Sumber, Cara Penularan, dan Agen Penyebab

Sumber/Cara Penularan Diketahui Investigasi + Control +++ Tidak Diketahui Investigasi +++ Control +

Agen Penyebab

Diketahui Tidak Diketahui

Investigasi +++ Control +++

Investigasi +++ Control +

Tujuan dari Investigasi KLB

1. 2. 3. 4. Memastikan diagnosis penyakit Menetapkan KLB Menentukan sumber dan cara penularan Mengetahui keadaan penyebab KLB

Pemastian Diagnosa (Poisoning)

Gejala klinis
Mual Sakit perut

N
15 15

%
83 83

Sakit kepala
Pucat Lemah Berkeringat dingin Muntah Sesak Nafas

14
11 8 8 7 3

78
61 44 44 39 16

Diagnosa Banding
BAKTERI Bacillus cereus MASA INKUBASI 0,5 6 jam 6 -15 jam GEJALA mual, muntah, kram perut dan diare Diare berair, kram perut dan sakit perut DURASI 24 jam SUMBER KONTAMINAN daging, susu, sayuran, ikan, makanan dari beras, kentang, pasta, keju, saus, pudding, sup, casserole (makanan yang dimasak dalam wadah tertutup) daging dan produk daging; daging unggas dan produk telur; salad seperti telur, ikan tuna, kentang, dan macaroni; produk roti seperti kue dengan isi krim, kue krim, dan chocolate clairs ; roti isi; dan susu dan produk susu

Staphylococcus aureus

1 8 jam rata-rata 4 jam

Escherichia Coli

5 48 jam rata-rata 10 24 jam

Clostridium Perfringens

6-22 jam

mual, 48 72 jam muntah, retching (sep erti muntah tetapi tidak mengeluarkan apa pun), kram perut, dan rasa lemas sakit kepala, kram otot, dan perubahan yang nyata pada tekanan darah serta denyut nadi Mual, muntah, kejang 24 72 jam perut (kadang berdarah), demam, mengigil, sakit kepala, sakit otot, kencing berdarah Diare, nyeri perut, 1 2 hari mual, muntah

makanan yang terkontaminasi oleh air yang tercemar oleh kotoran manusia. Sayur dan buah yang dimakan mentah Produk daging yang tidak disimpan dan dipanaskan sempurna

Pemastian Diagnosa Outbreak Diare

Frekuensi
No
1 2 3 4 5

Persentase
(%)
100,00 50,00 40,28 37,50 26,39

Gejala (n)
BAB cair/encer 3x dalam sehari Lemah Muntah Demam Mual 72 36 29 27 19

6
7 8 9 10 11 12 13 14

BAB tidak tertahankan

Pusing Keringat dingin BAB bau amis Dehidrasi Kram perut BAB disertai lendir BAB disertai darah Mata cekung

15
15 11 10 9 7 5 4 2

20,83
20,83 15,28 13,89 12,50 9,72 6,94 5,56 2,78

Gejala dan Tanda yang Ditemukan pada Penderita Mumbs

Pesentase (%) 100,0 86,2

No 1 2

Gejala Pembengkakan kelenjar di bawah telinga (parotis) Sulit membuka mulut Tidak enak badan (malaise) Nyeri rahang bagian belakang Demam

Jumlah kasus 87 75

3
4 5 6 7

69
69 66 64 61

79,3
79,3 75,9 73,6 70,1

Kehilangan nafsu makan

Sakit kepala

8
9 10

Nyeri otot
Nyeri telinga Orkitis

49
35 1

56,3
40,2 1,1

Menentukan sumber dan cara penularan

No Tempat Jumlah Persentase (%)

SMP N 1 Kokap

73

83,90

Pondok Pesantren Ittihadul

Mujtahidin

8,05

SMP N 1 Kokap dan Pondok Pesantren Ittihadul Mujtahidin 7 8,05

Total

87

100,00

Hasil Analisis Faktor Risiko KLB Parotitis di SMP N 1 Kokap Tahun 2010 (n=228)
No 1 2 3 4 Faktor risiko Riwayat Kontak Sekelas Alat makan/minum dipakai bersama Kebiasaan tidak selalu mencuci tangan Kebiasaan tidak selalu mencuci tangan dengan sabun Kebiasaan tidak selalu mencuci tangan dengan sabun sebelum makan Kebiasaan tidak bersin/batuk menutup mulut/hidung saat OR 2,40 4,53 1,18 95%CI 1,035,71 2,289,06 0,652,13 0,994,07 P 0,027 0,000 0,571

1,99

0,038

1,00

0,051,83

1,000

1,53

0,852,77 0,973,25 0,581,92 0,441,42 0,552,54

0,130

7 8 9 10

Kebiasaan meludah di sembarang tempat Kecukupan istirahat saat hari-hari biasa Kecukupan istirahat saat ujian Gizi kurang

1,77 1,06 0,79 1,19

0,048 0,849 0,397 0,626 54

Attack Rate (%) Jenis makanan

Makan Populasi Kasus Tidak Makan Populasi Kasus AR (%) RR

Jenis Makanan Nasi putih Mie instant Sate ayam

AR (%)

19
32 28 16 12

5
11 16 5 4

26,3
34,4 57,1 31,3 25,0

35
22 26 38 38

13
7 2 13 14

37,1 0,70
31,8 1,08 7,7 7,42

Lontong
Nasi Goreng Orak-arik Telur

34,2 0,91 36,8 0,67

21
12

4
1

19,0
5,6

33
42

14
17

42,4 0,44
40,5 0,20

Odds Ratio Jenis makanan

Jenis Makanan

OR 0,604 1,122 16,00 0,874 0,571

CI : 95% 0,176 2,067 0,353 3,567 3,150 81,266 0,250 3,056 0,154 2,116

p-value 0,420 0,844 0,000 0,833 0,399

Nasi putih
Mie instant Sate ayam Lontong Nasi Goreng Orak-arik Telur

0,319
0,133

0,087 1,159
0,015 - 1,133

0,075
0,037

Distribusi Kasus Berdasarkan Dusun Kec. Cawas Kab. Klaten

25 April 6 Juni 2011

Attack Rate (AR%) Berdasarkan Jenis Kelamin, Kelompok Umur, dan Tempat Tinggal
Populasi Rentan Jenis Kelamin Laki-laki Perempuan Kelompok Umur <1 tahun 1-5 tahun > 5 tahun Tempat Tinggal (Dukuh Brungkah) RT 16 RT 17 RT 18 Kasus AR (%)

219 232 5 23 423

37 35 1 4 67

16,9 15,1 20,0 17,4 15,8

133 189 129

7 39 26

5,3 20,6 20,2

Construct and interpret and epidemic curve

Kegunaan kurva epidemik

1 Menentukan cara penularan (Tipe kurva) 2 Identifikasi waktu paparan. 3 Mencari indeks case (Orang yang pertama sakit).

Outbreak Pattern of Spread

The overall shape of the epi curve can reveal the type of outbreak
1. Common source (sumber penyakit sama) 2. Propagated (sumber penyakit dari berbagai org/sumber) 3. Mix (common source and propagated)

How do I Make an Epi Curve?

1. Plot the number of cases of disease reported during an outbreak on the y-axis. 2. Plot the time or date of illness onset on the xaxis 3. Technical tips
a) Choice of time unit for x-axis depends upon the incubation period. b) Begin with a unit approximately one quarter the length of the incubation period. c) If the incubation period is not known, graph several epi curves with different time units

4. Epi curves are histograms

Common source Satu Sumber (Peak only one)

Y

Perhatikan : Skala ; 1/8 s/d masa inkubasi

Deskripsi menurut Waktu (0,5 s/d 6 jam) Outbreak keracunan makanan Common Source
Y
6

Masa inkubasi terpanjang

Masa inkubasi terpendek

Jumlah kasus

Waktu makan

0
15.00 15.30 16.00 16.30 17.00 17.30 18.00 18.30 19.00 19.30 20.00 20.30 21.30 22.30

X
Waktu

Perhatikan : Skala ; 1/8 s/d masa inkubasi

Outbreak Pattern of Spread-Propagated

1. Is spread from person to person. 2. Can last longer than common source outbreaks. 3. May have multiple peaks. 4. The classic epi curve for a propagated outbreak has progressively taller peaks, an incubation period apart

Propagated : Banyak Sumber, dari orang ke orang

Tanggal Mulai Sakit (minggu)

JUMLAH KASUS

14 12 10 8 6 4 2 0

Perhatikan : Skala ; 1/8 s/d masa inkubasi

Example of an Epi Curve for a Mix Propagated & Common Source Outbreak (sumur dan muntaber)

Perhatikan : Skala ; 1/8 s/d masa inkubasi

FIND WHO IS INDEKS CASE

Minimum-maximum method
1. Epidemi mulai 24 maret dan berakhir pada 5 april (Lama epidemi 12 hari). 2. Masuk dalam kisaran masa inkubasi penyakit tertentu (ex : tifoid 7-21 hari, mean 14 hari). 3. Kasus pertama terpapar > 7 hari sebelumnya yaitu tgl sebelum 17 maret (Masa inkubasi tifoid terpendek 7 hari). 4. Kasus terakhir terpapar sebelum 14 maret (masa inkubasi terpanjang 21 hari). 5. Hipotesis : paparan terjadi antara 14-17 Maret

Estimating the date of common source exposure Minimum-maximum method

21 hari 14 hari

7 hari

Cara lain (Masa inkubasi)

1. Tentukan rerata masa inkubasi (tifoid 14 hari. 2. Tentukan kasus median (kasus ke 41 secara kronologis dari 81 kasus). 3. Hitung ke belakang rerata masa inkubasi. 4. Hipotesis : paparan diduga tgl 15 Maret

Estimating the date of common source exposure Incubation period method

14 hari

Kurva epidemik Propagated Source KLB Parotitis

Masa incubasi: 12-25 hari (rata-rata 16-18 hari)

73

Penanggulangan sementara
(+; Respon, (+); Rendah, (++); sedang, (+++); tinggi

TERIMA KASIH