Environmental factors and an eco-epidemiological model of

Transcription

02/09/2012
IRGSC
Institute of Resource Governance and Social Change
Producing Knowledge, Inspiring Policy Innovation and Change
IRGSC
Acknowledgment
•
•
•
Environmental factors and
an eco-epidemiological
model of malaria in
Indonesia
Semua korban/penderita malaria
Responden + Data Collector Tim
Tim Entomolgist di lapangan
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Timor (Agus Samol+Imanuel Tamelan) + Kebumen (Agung C) + Sukabumi (Maman S)
Dinkes Prov NTT, Dinkes Kab se-Daratan Timor, Dinkes Kebumen, Dinkes Sukabumi
BPRV Salatiga
•
Pembimbing:
•
•
•
•
•
Penyandang Dana: ARC (Discovery) Grant Commonwealth of Australia
School of Environmental Planning - Griffith University
FAN
IRGSC think tank members
Bappeda NTT
•
•
Griffith University: Prof Pat Dale, A.Prof Neil Sipe, Prof Clyde Wild
Indonesia: Prof Sugeng M (UGM) + Dr Damar T Bowono (Litbang Kemenkes)
Ermi Ndoen
1st Lunch Seminar of IRGSC – Kupang, 24 August 2012. Website: http://www.sustainability-k-governance.net/index.html
IRGSC
IRGSC
Ho ho ho … Saya nyamuk Malaria
Topik diskusi hari ini ….
• Permasalahan Malaria
 dikaitkan dengan konteks NTT
• Research Fokus
• Hasil dan Diskusi
• Rekomendasi
• Penutup
No animal in the world has touched so directly
and profoundly the lives of so many human
beings. For all of history and all over the globe
she has been a nuisance, a pain, and an angel
of death. Mosquitoes have felled great leaders,
decimated armies, and decided the fates of
nation. …
Nama saya Anopheles
(Spielman & D'Antonio, 2001, p. xv,– “Mosquito - the Story of
Man's Deadliest Foe”)
IRGSC
Pembunuh terbesar sepanjang masa
IRGSC
Malaria dalam Angka
3.3 Miliar
106
24 Juta
Tidak sekadar
Angka kesakitan
dan kematian
Orang terkenal yang mati atau sakit malaria
Source: http://www.malariasite.com/malaria/history_victims.htm
Penduduk Dunia yang tinggal di daerah
endemis malaria (WHO, 2010)
Negara Endemis Malaria  Indonesia
termasuk top 10 Negara Endemis Malaria
Kasus malaria (confirmed) di seluruh dunia,
2010
325 ribu
Jumlah kematian akibat malaria di dunia,
2010
230 Ribu
Jumlah Kasus Malaria (Confirmed) di
Indonesia, 2012
432
Jumlah kematian akibat malaria yang
dilaporkan di Indonesia, 2010
Malaria
berdampak
pada
•
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•
•
•
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•
40 % public health expenditures (WHO, 2009)
30-50 % inpatient hospital admissions (WHO, 2009)
60% outpatient visit at Health Centers (WHO, 2009)
1.3% reduction in economic growth (WHO, 2009)
12 % reduction of income (WHO, 1998)
3-8 % School absenteeism (Trape et al, 1993)
Indonesia lost US$ 56.5 juta per tahun (UNDP, 2004)
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02/09/2012
IRGSC
http://gamapserver.who.int/gho/interactive_charts/malaria/cases/atlas.html
IRGSC
IRGSC
http://gamapserver.who.int/gho/interactive_charts/malaria/cases/atlas.html
IRGSC
Malaria = Penyakit infeksi protozoa dari genus Plasmodium
Ada lebih dari 50 jenis parasit Plasmodium,
hanya 5 yang menularkan malaria:
1.
P. malarie (Golgi, 1886  Italia)
2.
3.
P. vivax (Golgi, 1886  Italia)
P. falciparun (Celli & Marchiava, 1890)
4.
5.
P. ovale (Stephens, 1922)
P. knowlesi (Singh et al., 2004; Cox-Singh &
Singh, 2008)
Types of Parasite
P. vivax
Agent factors
Geographical Distribution


Penyebaran luas pada daerah tropis dan
subtropis
P vivax banyak di temukan di Indonesia
P. falciparum

Penyebarannya luas terutama pada daerah
tropis dan subtropis.
P. malariae

Penyebarannya luas, tapi mengelompok pada
lokasi geografi tertentu (cluster).
P. ovale

Kebanyakan di daerah tropical Africa,
terutama di Pantai Barat Afrika
P. knowlesi

Serawak – Semenanjung Malaysia
IRGSC
IRGSC
The geographic distribution of ten important malaria vectors in Indonesia
Host (Pejamu)
• Manusia (host intermediate)
• Nyamuk Anopheles (host definitive)
(MoH, 2005)




>400 Anopheles species di dunia
~ 80 Anopheles species yang dapat menularkan malaria
Ada ~ 24 Anopheles species malaria di Indonesia
Ada ~ 10 Anopheles species dominant malaria di Indonesia
(O'Connor & Soepanto, 1989; Takken et al., 1990; Laihad, 2000).
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IRGSC
Usia : anak > rentan
Jenis kelamin : ibu hamil dpt anemia > berat
Ras: ada ras dg kekebalan alamiah
Riwayat malaria sebelumnya
Cara hidup : sering di luar rumah malam hari
Sosial ekonomi : sosek di daerah endemis erat hubungan dg infeksi
malaria
Status gizi : gizi < baik rentan infeksi
Immunitas : immunitas alami bisa terbentuk jika tinggal di daerah
endemis
•
•
Impact of malaria in pregnancy
Manusia (host intermediate)
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•
IRGSC
Pregnancy
-Increases susceptibility
-More infections
-More severe
Pregnant woman
-Asymptomatic to acute
clinical illness / death
-Severe anaemia
Effects depend on
-Malaria endemicity
-Maternal age
-Gravidity
-HIV status
Foetus
-Miscarriage
-Stillbirth
-Low birth weight (2x)
IUGR / Preterm
Longer term effects
-Neonatal and post neonatal mortality
-Immune modulation (susceptibility)
-Infant anaemia
-Infant growth?
-neuro-cognitive development?
IRGSC
IRGSC
Beban Malaria Pada Kehamilan
Data Pendukung (2) lanjutan…
Sumber : Poespoprodjo,dkk;2008 (RSMM Timika 2004 – 2008)
1. Malaria Pada Ibu Hamil
3. Bayi Berat Lahir Rendah (< 2500 gr)
Ibu dengan Malaria : OR = 1.9 [95%CI 1.6-2.3],p<0.0001
Ibu dengan Pf -182g [95%CI: 146-217], p<0.0001
Pv -108g [95%CI: 56-161], p=0.003
18% (808/4419) Ibu Hamil terkonfirmasi menderita malaria pada saat masuk rumah sakit
untuk bersalin.
60% P. falciparum, 32% P.vivax, 4.5% Mixed, 3.5% Lainnya
Hanya 30% di antaranya yang disertai demam/gejala klinis
4. Kematian Perinatal
Ibu dengan Pf : OR = 2.9 [95%CI: 1.9-4.2], p<0.0001
3.9% (32/808) menunjukkan tanda-tanda malaria berat
Anemia berat : OR=2.6 [95%CI,1.7-3.8], p<0.0001
Satu kematian ibu : P.vivax dengan sepsis bakterial berat
2. Anemia pada Ibu Bersalin yang berhubungan dengan Malaria
5. Kelahiran Prematur
Ibu dengan Malaria : OR= 1.5 [(95%CI, 1.2-1.9), p=0.001]
Maternal Pf : Hb Drop of 1.2 g/dl; Anemia Berat :OR 2.8 [95%CI 2.1-3.7],p<0.0001
Maternal Pv : Hb Drop of 0.50 g/dl; Anemia Sedang :OR 1.5 [95%CI 1.1-2.0],p=0.006
IRGSC
Status Kesehatan Anak di Daerah Endemik Malaria
Kematian neonatal Kematian bayi
(per 1000 LH)
(per 1000 LH)
24
41
64
Papua Barat
21
36
62
Maluku
25
59
93
Maluku Utara
32
51
74
NTT
31
57
80
Rata-rata
Indonesia Timur
Nasional
Lancet: Global causes of child deaths – Malaria = 7%
Kematian balita
(Per 1000 BLT)
Papua
NTB
IRGSC
34
72
92
27.8
52.7
77.5
20
34
Data di NTT ?
45
Sumber : SDKI 2007
Sumber : http://www.sciencedirect.com/science/article/pii/S0140673612605601
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02/09/2012
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Status Derajat Kesehatan Masyarakat di NTT
Angka Kematian
NTT
BAYI/IMR (Per 1000 LH)
IBU/MMR (Per 100.000 LH)
BALITA (Per 1000 LH)
PREVALENSI GIZI
Gizi Buruk
Gizi Kurang
Gizi Baik
Gizi Lebih
Umur Harapan Hidup
Laki-Laki
Perempuan
L/P
IRGSC
Situasi Malaria di NTT
Annual Parasite Incidence (2007-2011)
INDONESIA
57
306
80
34
228
44
9,4%
24,2%
64,4%
2,0%
5.40%
13.40%
77.20%
4.30%
62,9 THN
67,2 THN
65,1 THN
70,5 THN
40
30
20
10
0
2007
32
API
2008
28
2009
31
2010
29
2011
26
Source: Profile Kesehatan NTT Tahun 2009
Source: Data Program Malaria, DINKES NTT
IRGSC
IRGSC
Situasi Malaria di NTT - 2011
API BY DISTRCITS IN NTT - 2011
200
Demographic profile
187
Malaria Profile - 2011
API (0/00)
POPULATION
4,694,269
180
160
Clinical Cases
99,375
Malaria Tested
470,800
Confirmed
121,599
140
Babies
Mal +
115,357 5,336
Pregnant Women
126,941 3,704
120
100
API
46.3
29.2
AMI
21.17
API
25.90
78
80
Confirmed Malaria Cases by Age Groups
67
60
45
36
40
32
32
10 - 14 Yo
12%
28
25
23
20
19
16
20
16
14
13
9
6
3
3
2
5-9 Yo
16%
Other
50%
-
Preg Women
3%
Unkown
2%
1-4 Yo
18%
Babies
4%
IRGSC
Malaria Program Performances (Lab) - 2011
Clinical Cases
99,375
= 45 % of Total Malaria Cases
(Clinical + Confirmed)
Malaria Tested
470,800
Lab
RDT
365,494
78%
105,306
22%
Microscopy Quality
%
85.08
77.33
22.93
API and Error Rate Microscopy
200.00
API
150.00
R² = 0.7742
100.00
50.00
API
Linear (API)
0.00
10.00
20.00
30.00
Error rate (%)
40.00
50.00
4.39
18.00
15.86
11.74
45.00
3.05
1.96
100.00
Malaria Program Performances (Treatment & Protection) - 2011
POPULATION
4,694,269
ABER = 10%
Sensitivity
Spesifity
Error Rate
5,336
21,884
19,287
14,278
54,723
3,704
2,387
121,599
60.00
Range
50 - 100 %
58 - 100 %
2.6 - 48%
Confirmed
121,599
API
25.90
Malaria Tested
470,800
Confirmed
121,599
ACT TREATMENT
RATE
API
25.90
SPR
API and Error Rate Microscopy
District
Lembata
Sikka
Nagekeo
Ende
Belu
Average Prov
Sumba Barat
TTU
Kota
Manggarai
API
187.49
67.38
35.66
31.97
27.84
25.90
19.63
6.04
2.91
1.74
ERROR RATE
48.19
37.78
12.26
21.72
21.23
22.93
11.43
3.33
2.63
8.70
Note: Crosscheck data is not completed yet.
Source: Dinkes NTT, April 2012
Type of Parasites
IRGSC
Babies
1-4 Yo
5-9 Yo
10 - 14 Yo
> 15 Yo
Preg Women
Unkown
TOTAL
> 15 Yo
45%
126,941
94,888
3,704
60,211
49.52 %
54,247
31
44.61 %
0.03%
Po
-
-
Mix
7,110
Total
121,599
25.83
% Pf
55.36
5.85 %
100.00
Total
BEDNET
MALARIA SCREENING
FOR PREGNANT WOMEN
Pregnant Women
Mal Screening
Mal Positive
Pf
Pv
Pm
75%
4%
69,503
57.16 %
Routine ANC
Pregnant Women
FIC
Campaign
5 Yo Children
Rep women + Mal
Total
67,371
39,371
33,444
32,180
8,382
180,748
37.27
21.78
18.50
17.80
4.64
100
Preg Wmen
Babies
126,941
115,357
Bednet
106,742
33,444
Percent
84%
29%
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02/09/2012
IRGSC
Environmental
factors
IRGSC
Kenapa Faktor lingkungan?
Malaria transmission
cannot be separated
from dynamic
interaction between
the classical triad of
host, agent and
environment, the
three major
components of this
disease (Aron & Patz,
2001).
IRGSC
IRGSC
Theory Blum  Status Kesehatan
Perilaku nyamuk
Theory Blum (1974)
mating - host seeking - blood feeding – resting - ovipositing
Derajat kesehatan masyarakat
dipengaruhi oleh 4 faktor yaitu :
Udara - Cuaca
1.Lingkungan,
2. Perilaku,
3. Pelayanan kesehatan, dan
4. Keturunan
IRGSC
Kata Malaria berasal dari bahasa Itali:
- mal (=bad) dan
- aria (=air)
- Menjelaskan bahwa sakit malaria disebabkan
oleh “miasma” yang berasal dari rawa-rawa di
sekitar Roma.
- Juga sering dikenal dengan “jungle fever, marsh
fever, paludal fever, or swamp fever”.
Air
Jenis-jenis tempat perindukan
IRGSC
Telur
Jentik saat
istirahat di
air
Jentik yang
sudah mau
jadi nyamuk
5-7 hari
jentik jadi
nyamuk
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IRGSC
Nyamuk malaria aktif
mencari darah sejak
matahari terbenam
hingga matahari terbit
•
•
Satu sporozoite bisa
menginfeksi host vertebrata.
10 sporozoites dari P. vivax
bisa 100% menyebabkan
malaria pada manusia
Infective
Dose
IRGSC
IRGSC
Hubungan Causal Penyakit
Mengapa
Eco-epidemiology?
Traditional Epidemiological
Framework
Ecological - Epidemiological
Framework
Agent
Social
SYSTEMS
Host
Environment
Ecological
Global
Epidemics
Disease
Paul R. Epstein, M.D., M.P.H.
http://med.harvard.edu/chge
IRGSC
Proses evolusi modern epidemiology  Eco-epidemiology
IRGSC
Eco-epidemiology Concept
Konsep eco-epidemiology malaria di proposed pertama kali
oleh Bruce-Chwatt (Gilles, 1993) dan kemudian mulai
dikembangkan oleh World Health Organization (WHO, 2006a).
Epidemiology is “the study of the
distribution and determinants of healthrelated states and events and the
application of this study to control of
health problems” (Last, 1996, p. 1099)
Source : Susser & Susser, (1996a, p. 676)
Eco-epidemiology is defined as the
“study of ecological influences on
human health”.
It is also defined as a “Conceptual
approach combining molecular,
societal, and population-based aspects
to study a health-related problem”
(Medical Dictionary, 2009).
6
02/09/2012
IRGSC
IRGSC
Beberapa Konsep Eco-epidemiology malaria
1. Lancet: presented a systematic review of reducing the burden of malaria in different
ecological settings from the past to the present emphasising that a sustainable
strategy for malaria control approach, with respect to different ecological settings:
1) malaria of deep forest, forest fringe and hills;
2) rural malaria attributable to water resources development and management;
3) rural malaria attributable to wetlands, rivers, streams, coast and nonagricultural man-made habitats;
4) urban and peri-urban malaria. (Keiser, et al, 2005)
2. In Venezuela, Morales (2006) highlighted the importance of eco-epidemiology as a
new vision and discipline in fighting and preventing diseases including malaria, and
its use in current public health policy.
Beberapa contoh
pendekatan ecoepidemiolagy malaria
di Indonesia
Species
Sanitation
3. In India, the National Institute of Malaria Research (NIMR), through the integrated
disease vector project, also used the eco-epidemiological settings to study malaria
and its control with respect to different ecotypes and malaria epidemiology (NIMR,
2007)
Source: Takken, et al. (1990)
IRGSC
IRGSC
Variable Eco-epidemiological
sebagai faktor risiko malaria yang diteliti
Konsep Eco-epidemiological model dalam penelitian
IRGSC
Study Areas
IRGSC
Research Q 1
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02/09/2012
IRGSC
IRGSC
Significant results
Research Q 2 - 3
Belu memiliki kasus
malaria tertinggi
dibanding kab/kota lain
di Timor Barat
Matrix of the mean
differences of the average
AMI (logarithmic
transformed ) by districts
in West Timor 2003–2006
IRGSC
IRGSC
T-test result for mean difference of average AMI (logarithmic
transformed) between villages located on the districts boundary
and non-boundaries of West Timor
Kasus malaria lebih
tinggi pada desa-desa
yang terletak pada
“zona perbatasan”
ANOVA results investigating differences in average AMI
(log-transformed) by topographic settings in West Timor
Semakin tinggi
altititude semakin
rendah kasus malaria
Spatial distribution of average
malaria cases (2003-2006)
boundary villages on the districts’
boundary in West Timor
1st
Average malaria incidence
(2003-2006) by altitude in West Timor
Lunch Seminar of IRGSC – Kupang, 24 August 2012. Website: http://www.sustainability-k-governance.net/index.html
IRGSC
1st
IRGSC
Cuaca VS Malaria
The correlation results between
the population density and the
average monthly malaria incidence
in West Timor, 2003–2006
Pearson correlation result for rainfall and monthly malaria incidence in
nine villages of West Timor, 2003–2006
Pearson correlation result for temperature, relative humidity, wind speed
and monthly malaria incidence in Lasiana Village of West Timor, 2003–2006
Semakin tinggi
kepadatan penduduk
semakin rendah kasus
malaria
Malaria spatial distribution based on population density by villages in West Timor
Kasus malaria dipengaruhi oleh jumah hari hujan, suhu dan
kelembaban
Pada musim kering, jumlah desa yang berisiko tinggi malaria
lebih banyak dibanding pada musim hujan
8
02/09/2012
IRGSC
Entomology survey sites – West Timor
IRGSC
Survey entomology di West Timor
Average local weather condition in West Timor
during entomological survey
IRGSC
A schematic topographical feature of malaria vectors distribution in West Timor
IRGSC
25
70
20
60
Landing Rate (per hour)
1st
1st
15
10
5
50
40
30
20
10
0
1800-
1900-
2000-
2100-
2200-
2300-
2400-
0100-
0200-
0300-
0400-
0500-
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
0
1800- 1900- 2000- 2100- 2200- 2300- 2400- 0100- 0200- 0300- 0400- 05001900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500 0600
Time of Night
Time of Night
The linear fitted model for An. aconitus host seeking activities
The 2O polynomial curve fitted model for An. barbirostris host
seeking activities
25
120
100
80
60
40
20
20
15
10
5
0
0
1800-
1900-
2000-
2100-
2200-
2300-
2400-
0100-
0200-
0300-
0400-
0500-
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
1800-
1900-
2000-
2100-
2200-
1900
2000
2100
2200
2300
The 3O polynomial curve fitted model for An. subpictus host
seeking activities
IRGSC
2300-
2400-
0100-
0200-
0300-
0400-
0500-
2400
0100
0200
0300
0400
0500
0600
Time of Night
Time of Night
2O
The
polynomial curve fitted model for An. vagus host
seeking activities in West Timor
IRGSC
Beberapa faktor manusia yang berkorelasi nyata
dengan kejadian malaria
Types of potential
mosquito breeding
places in research areas
Mangrove (a), creek (b), animal
hoof prints (c1-c4), stagnant
water in the river (d) and rice
field with algae
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02/09/2012
IRGSC
IRGSC
Beberapa hasil significant dan rekomendasi
Vector malaria yang
significant di Timor
Barat dan
rekomendasi
intervensi
IRGSC
Recommendations for Future Malaria Control
1. Penularan malaria bersifat lokal spesifik, karena itu pendekatan ekoepidemiologis sangat membantu dalam penentuan strategi dan
priorisasi program intervention dengan melihat berbagai faktor ekologis
2. Penggunaan teknologi GIS – pemahaman tentang faktor cuaca – perilaku
vektor – perilaku manusia di daerah malaria sangat bermanfaat dalam
proses pengambilan keputusan berbasis bukti untuk program malaria
3. Untuk konteks West Timor, prioritas program malaria terutama pada
daerah pesisir dan desa-desa pada “zona perbatasan” .
4. Kelompok rentan seperti Ibu hamil dan Balita harus mendapat perhatian
dalam program pencegahan dan penanggulangan malaria.
5. Di West Timor Anopheles species umumnya “feed and rest indoors”.
Karena itu program pemberantasan nyamuk yang effektif adalah
kelambu dan tidak anjurkan untuk IRS.
6. Penguatan quality assurance dalam progam malaria: logistik + lab
IRGSC
IRGSC
Beberapa publikasi malaria
1.
Relationships between anopheline mosquitoes and topography in West Timor and Java, Indonesia.
Ermi Ndoen, Clyde Wild, Pat Dale, Neil Sipe, Mike Dale.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939620/
2.
DUSK TO DAWN ACTIVITY PATTERNS OF ANOPHELINE MOSQUITOES IN WEST TIMOR AND JAVA,
INDONESIA. Ermi Ndoen, Clyde Wild, Pat Dale, Neil Sipe and Mike.
http://www.tm.mahidol.ac.th/seameo/2011-42-3/09-4743.pdf
3.
Mosquito Longevity, Vector Capacity, and Malaria Incidence in West Timor and Central Java, Indonesia.
Ermi Ndoen, Clyde Wild, Pat Dale, Neil Sipe, Mike Dale. http://www.isrn.com/journals/ph/2012/143863/
4.
MALARIA IN INDONESIA: A SUMMARY OF RECENT RESEARCH INTO ITS ENVIRONMENTAL
RELATIONSHIPS. Pat Dale, Neil Sipe, Sugi Anto, Bangkit Hutajulu, Ermi Ndoen, Meisy Papayungan, et al.
http://www.tm.mahidol.ac.th/seameo/2005_36_1/01-3358.pdf
5.
A novel approach for modeling malaria incidence using complex categorical household data: The
minimum message length (MML) method applied to Indonesian data. Gerhard Visser, Pat Dale, David
Dowe, Ermi Ndoen, Mike Dale, Neil Sipe. Computational Ecology and Software, 2012, 2(3):140-159.
http://www.iaees.org/publications/journals/ces/articles/2012-2(3)/a-novel-approach-for-modelingmalaria-incidence.pdf
IRGSC
Pencegahan
Anti malarial drug
Desmond Tutu Archbishop Emeritus
Kelambu
Repellent
Kawat nyamuk
ACT
SP
Quinine
Primaquine
“…We have the means. We often lack
the political will. Let us reverse this
trend and make our world malaria
free”
http://www.mobilising4malaria.org/pages/en/quotes_and_statements.html#tutu
Vector Control + Modifikasi Lingkungan
10

Environmental factors and an eco-epidemiological model of

Transcription

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Vol. 22, No.3, Sep 2009

normative e linee d`azione per la conservazione delle memorie digitali

Conflitti di interesse (continua) - Bristol

localization and broadband follow-up of the gravitational

here - 47th Annual Meeting of the Society for Invertebrate Pathology

Corso di Laurea Economia e M Studio del Risk Managem

Pengaruh Kepemimpinan Paternalistik Terhadap Komitmen PNS

Untitled - Direktorat Jenderal Kefarmasian dan Alat Kesehatan

conference proceedings - OpenstarTs

Dasar Perubahan Iklim Negara

multitexco - Tex Club Tec

analisis pengaruh profitabilitas, kebijakan utang, kebijakan dividen

sistemi di gestione: miglioramento continuo e