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Pengendalian dan pemberantasan penyakit 5-6/2014

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  1. Pengendalian dan pemberantasan penyakit5-6/2014 DISIAPKAN OLEH PROF. DR.DRH.PRATIWI, TS. MS DRH.ROSITAWATI, I. MP PTS-RST-PKH-5-6-2014

  2. OUTBREAK INVESTIGATION PTS-RST-PKH-5-6-2014

  3. Definition • Outbreak investigation purposes • The pattern of temporal, spatial andanimals • 10 steps outbreak investigation PTS-RST-PKH-5-6-2014

  4. What is an outbreak ? Definitions • Occurrence of more cases of disease than expected : • - in a given area • among a specific group of population • over a particular period of time OutbreakEpidemiology - Study of a disease clusteror epidemic in order to control or prevent further spread of the disease in the population. PTS-RST-PKH-5-6-2014

  5. PENGENDALIAN BERDASARKAN PERWILAYAHAN (ZONING) PTS-RST-PKH-5-6-2014 • DAERAH TERTULAR: daerah yang sudahdinyatakanadakasussecaraklinis, PA dan HP sertadikonfirmasidgnhasillaboratorium • DAERAH TERANCAM: daerah yang berbatasanlangsungdengandaerahtertularatautidakmemilikibatasanalamdengandaerahtertular • DAERAH BEBAS: daerah yang dinyatakanmasihbelumadakasussecaraklinis, PA dan HP ataumemilikibatasanalam (propinsi, pulau)

  6. SISTEM KEWASPADAAN DINI(EARLY WARNING SYSTEM) • SUBSISTEM KESIAGAAN DINI - PENGAMATAN DINI - PENANGGULANGAN DINI PTS-RST-PKH-5-6-2014

  7. SISTEM KEWASPADAAN DINI(EARLY WARNING SYSTEM) • SUBSISTEM PERAMALAN WABAH - PREDIKSI KEJADIAN WABAH - TINDAKAN ANTISIPASI PTS-RST-PKH-5-6-2014

  8. Outbreaks PTS-RST-PKH-5-6-2014 2 or more cases associated in time and place E. coli 0157:H7 (Northwest) Cryptosporidium (Milwaukee) Norwalk virus (Cruise ships) Vibrio cholerae (South America) Listeria (New York, New Jersey, CT)

  9. What is infectious disease epidemiology? • Infectious disease epidemiology • Two or more populations • A case is a risk factor • The cause often known (www) PTS-RST-PKH-5-6-2014 Epidemiology Deals with one population Risk  case Identifies causes

  10. Agents PTS-RST-PKH-5-6-2014 Clostridium botulinum, C. perfringens Staphylococci, Salmonella, Shigella Campylobacter jejuni, E. coli 0157:H7 Vibrio parahaemolyticus Hepatitis A, Norwalk virus, Rotavirus Calicivirus, Listeria monocytogenes Cryptosporidium, Giardia, Bacillus cereus Toxoplasma gondii, Cyclospora

  11. Food borne Diseases • Infection • long incubation period (days) • diarrhea, nausea, vomiting, abdominal cramps. Fever often • Salmonella, • Hepatitis A • Listeria, Giardia • Vibrio, Campylobacter • Norwalk virus • Intoxication • short incubation period (minutes - hours) • Vomiting, nausea, double vision, weakness, numbness, disorientation • C. botulinum • Staph aureus • certain fish/ shellfish PTS-RST-PKH-5-6-2014

  12. Natural Barriers to Infection PTS-RST-PKH-5-6-2014 Stomach acid pH 2 GI Tract immune system Normal intestinal flora Bile acids and digestive enzymes

  13. Increased Susceptibility PTS-RST-PKH-5-6-2014 Gastrectomy acid blockers for ulcers antacids, excessive consumption of water buffering capacity of food- milk, fatty foods antibiotic therapy very young, old immunocompromised stress, poor hygiene, underdeveloped areas

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  15. Retrospective investigation • Often the outbreak exists since days, weeks,months • Many cases already occurred • Count on the memory of people • Many data already collected; use them or start all • over? • Never too late, but more difficult PTS-RST-PKH-5-6-2014

  16. Steps in Investigating an Outbreak • Establish the existence of an outbreak • Confirm the diagnosis • Define a case and count cases • Perform descriptive epidemiology (person, place and time) • Determine who is at risk • Develop hypotheses explaining exposure & disease PTS-RST-PKH-5-6-2014

  17. Steps in Investigating an Outbreak • Evaluate hypotheses • As necessary, reconsider/refine hypotheses and execute additional studies • additional epidemiologic studies • other types of studies – laboratory, environmental • Communicate findings • written report • presentations • Implement control and prevention measures PTS-RST-PKH-5-6-2014

  18. Confirm the Existence of an Outbreak Definition of outbreak • One case – for diseases of epidemic potential • (e.g., measles, cholera) • More than the expected number of cases – for • endemic diseases • Sometimes is quantitative threshold • (e.g.meningococcal meningitis) Importance of a good surveillance system for early warning PTS-RST-PKH-5-6-2014

  19. Verify the outbreak • Determine whether there is an outbreak – an excess number of cases from what would be expected • Establish a case definition • Non-ambiguous • Clinical / diagnostic verification • Person / place / time descriptions • Identify and count cases of illness PTS-RST-PKH-5-6-2014

  20. Plot an Epidemic Curve • Graph of the number of cases (y-axis) by their date or time of onset (x-axis) • Interpreting an epidemic curve • Overall pattern: increase, peak, decrease • Type of epidemic? • Incubation period? • Outliers: • Unrelated? • Early or late exposure? • Index case? Secondary cases? PTS-RST-PKH-5-6-2014

  21. Endemic vs. Epidemic No. of Cases of a Disease Epidemic Endemic Time PTS-RST-PKH-5-6-2014

  22. Vector-borne Disease • Starts slowly • Time between the first case and the peak is comparable to the incubation period. • Slow tail PTS-RST-PKH-5-6-2014

  23. Point Source Transmission • This is the most common form of transmission in food-borne disease, in which a large population is exposed for a short period of time. PTS-RST-PKH-5-6-2014

  24. Continuing Common Source or Intermittent Exposure • In this case, there are several peaks, and the incubation period cannot be identified. PTS-RST-PKH-5-6-2014

  25. Descriptive Epidemiology • TIME, PLACE, PERSON • May be possible to answer: • Who is at risk? • What is source of infection? • What is mode of transmission? PTS-RST-PKH-5-6-2014

  26. Descriptive Epidemiology - Time • Distribution of cases by date of onset • X axis: time Y axis: number of cases • Shows: • Time limits / duration of the outbreak • Peak / incubation period • Form of curve: evolution of outbreak • Formulate hypothesis regarding source PTS-RST-PKH-5-6-2014

  27. Cycle of Foodborne Disease Control and Prevention Surveillance Prevention Measures Epidemiologic Investigation Applied Research PTS-RST-PKH-5-6-2014

  28. Confirm the Diagnosis • Talk with health workers • Examine cases yourself ! • Laboratory testing (e.g., malaria, cholera, hemorrhagic fevers, etc.) PTS-RST-PKH-5-6-2014

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  32. Epidemiologic Curve

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  37. Recommend control measures • Control of present outbreak • Prevention of future similar outbreaks PTS-RST-PKH-5-6-2014

  38. Descriptive Epidemiology - Person • Numerators • Describe cases in terms of • age, sex, • other parameters : refugee / displaced / residents • immunized , not immunized • Denominators • Distribution in the overall population (age, sex,...) • Compare rates to identify high risk groups PTS-RST-PKH-5-6-2014

  39. Descriptive Epidemiology - Place • Map cases: identify geographic places at risk • Determine where disease acquired: Home, work, travel, etc.. PTS-RST-PKH-5-6-2014

  40. Information to Collect on Cases Personal information • Age • Sex • Place of residence (address) • Other relevant “exposures” • Refugees vs locals • Food source • Water source • Ethnicity, religion, etc. PTS-RST-PKH-5-6-2014

  41. Information to Collect on Cases Disease data • Date of onset of symptoms • Clinical symptoms and signs • Immunized or not (measles, meningitis) • Laboratory results (if any) • Duration of disease, outcome (death, cured,..) • Treatment received PTS-RST-PKH-5-6-2014

  42. Develop Hypotheses • Often obvious from descriptive epidemiology • Formulate idea about source of outbreak and mode of transmission PTS-RST-PKH-5-6-2014

  43. Test Hypotheses • Cross – sectional study? • Cohort study • Case – control study • Identify cases • Select control group • Possibly matched on age or sex or location • Community control, clinic control etc. • Compare exposures among cases and controls • Calculate odds for various exposures PTS-RST-PKH-5-6-2014

  44. Write a Report • Clarifies your own ideas / synthesis • Presents data and conclusions to anyone interested • Often epidemiologist don’t implement interventions • Must communicate to those who will intervene • Advocacy: MOH, UN, other NGOs, donors • Basis for future reference PTS-RST-PKH-5-6-2014

  45. Implement - Take ACTION Interventions include • Prevention of further cases • Control of transmission and source of infection • Improve case management, lower case-fatality rate PTS-RST-PKH-5-6-2014

  46. Terimakasih Selamat Belajar PTS-RST-PKH-5-6-2014