Bundle of Acads 17/18

Editor:

Special thanks to: Adriana Viola Miranda, Alessa FahiraAndi Gunawan Karamoy, Ariel Valentino, Assyifa Gita Firdaus, , Averina Geffanie, Brian Mendel, Fabiola Cathleen, Julius Calvin, Karina Teja Putri, Kelvin Theandro Gotama, Kristian Kurniawan, Marco Raditya, Muhammad Iqbal Adi Pratama, Nadya Johanna Raksheeth Agarwal, and all members of AMSA-UI 2017/2018 For contributions spent in making this bundle publishing possible

Academic AMSA-UI 2017/2018

NRPC2018

National Research Proposal Competition

AMSA-Indonesia Bundle of Acads AMSA-UI 2017/2018

NRPCAMSC2018

Research Project Proposal

Bundle of Acads AMSA-UI 2017/2018

Hubungan antara Pengetahuan dan Persepsi terhadap Tuberkulosis Paru terhadap Kepatuhan Pengobatan Anti-TB di Indonesia: Studi Multi-center Proposal Riset Nasional AMSA-Indonesia

Diusulkan Oleh: Alessa Fahira/1506668063 – AMSA-UI Bashar Adi Wahyu Pandhita/1506788326 – AMSA-UI Daniel Martin Simadibrata / 1506711206 – AMSA-UI Kelvin Theandro Gotama /1506788490 – AMSA-UI

Asian Medical Students Association Indonesia (AMSA-Indonesia) 2016 i

LEMBAR PENGESAHAN 1. Judul Proposal: Hubungan antara Pengetahuan dan Persepsi terhadap Tuberkulosis Paru terhadap Kepatuhan Pengobatan Anti-TB di Indonesia: Studi Multi-center 2. Nama Penulis: a. Alessa Fahira (150668063) b. Daniel Martin Simadibrata (1506711206) c. Kelvin Theandro Gotama (1506788490) d. Bashar Adi Wahyu Pandhita (1506788326) 3. Institusi: Fakultas Kedokteran Universitas Indonesia Depok, 1 November 2017 Mengetahui dan Menyetujui: Ketua Tim Peneliti

Representative AMSA-UI

Alessa Fahira

Armand Achmadsyah

Dosen Pembimbing

dr. Mardiastuti H Wahid

ii

Halaman Pernyataan Orisinalitas Karya National Research Proposal Competition “Infection Control: Old Problems, New Challenges�

1. Judul Proposal : Hubungan antara Pengetahuan dan Persepsi terhadap Tuberkulosis Paru terhadap Kepatuhan Pengobatan Anti-TB di Indonesia: Studi Multi-center 2. Nama Penulis: e. Alessa Fahira (150668063) f. Daniel Martin Simadibrata (1506711206) g. Kelvin Theandro Gotama (1506788490) h. Bashar Adi Wahyu Pandhita (1506788326) 3. Institusi: Fakultas Kedokteran Universitas Indonesia 4. Alamat Institusi: Jl. Salemba Raya No. 4 Kami yang bertanda tangan dibawah ini menyatakan bahwa memang benar proposal penelitian yang berjudul Hubungan antara Pengetahuan dan Persepsi terhadap Tuberkulosis Paru terhadap Kepatuhan Pengobatan Anti-TB di Indonesia: Studi Multi-center pada perlombaan National Research Proposal Competition belum pernah dipublikasikan sebelumnya dan merupakan karya asli hasil karya penulis. Demikian pernyataan ini kami buat dengan sebenarnya dan apabila terbukti terdapat pelanggaran di dalamnya maka kami siap untuk didiskualifikasi dari kompetisi ini sebagai bentuk tanggung jawab kami.

Depok, 1 November 2017

Alessa Fahira iii

KATA PENGANTAR

Puji syukur kami naikkan kepada Tuhan Yang Maha Esa atas berkat dan rahmat-Nya, sehingga kami dapat menyelesaikan penulisan karya tulis yang berjudul “Hubungan antara Pengetahuan dan Persepsi terhadap Tuberkulosis Paru terhadap Kepatuhan Pengobatan Anti-TB di Indonesia: Studi Multi-center�. Kami juga mengucapkan terima kasih kepada pihak-pihak yang telah membantu dalam karya tulis ini yaitu dosen pembimbing yang telah membantu dalam pembuatan karya tulis ini, orang tua yang telah memberi dukungan kepada kami, dan piihak – pihak lain yang tidak dapat disebutkan satu per satu.

Penulis berharap agar karya tulis ini dapat bermanfaat bagi masyarakat. Namun, karya tulis ini tidak akan luput dari kesalahan sehingga penulis terbuka akan masukan, kritik, dan saran. Semoga karya tulis ilmiah ini dapat memberikan manfaat terhadap masyarakat.

Jakarta, 01 November 2017

Penulis

iv

DAFTAR ISI

Lembar Pengesahan ...................................................................................................... ii Halaman Pernyataan Orisinalitas Karya ...................................................................... iii Kata Pengantar ............................................................................................................. iv Daftar isi........................................................................................................................ v Pendahuluan .................................................................................................................. 1 Latar belakang ................................................................................................... 1 Rumusan Masalah ............................................................................................. 2 Identifikasi Masalah .......................................................................................... 2 Pertanyaan Penelitian ........................................................................................ 2 Hipotesis ........................................................................................................... 2 Tujuan ............................................................................................................... 2 Manfaat ............................................................................................................. 3 Tinjauan Pustaka ........................................................................................................... 4 Tuberkulosis...................................................................................................... 5 Pengobatan Tuberkulosis .................................................................................. 5 Prognosis Tuberkulosis ..................................................................................... 6 Hubungan antara Pengetahuan dan Persepsi Pasien TB terhadap TB dengan Kepatuhan pasien terhadap Pengobatan ........................................................... 7 Kerangka Konsep .............................................................................................. 8 Metodologi Penelitian ................................................................................................... 9 Ruang Lingkup Penelitian............................................................................... 10 Desain Penelitian ............................................................................................ 10 Identifikasi Variabel........................................................................................ 10 Definisi Operasional Variabel......................................................................... 10 v

Populasi dan Subjek Penelitian ....................................................................... 10 Kriteria Inkusi dan Eksklusi............................................................................ 10 Teknik Pengambilan Sampel .......................................................................... 11 Instrumen Penelitian ....................................................................................... 11 Cara Pengumpulan Data ................................................................................. 12 Rancangan Penelitian ...................................................................................... 12 Alur Penelitian ................................................................................................ 13 Daftar Pustaka ............................................................................................................. 14

vi

BAB I PENDAHULUAN 1.1 Latar Belakang

Tuberkulosis (TB) masih menjadi permasalahan kesehatan di Indonesia yang tak kunjung terselesaikan, walaupun telah terjadi progres signifikan dalam pengurangan jumlah kasus TB dalam dua dekade terakhir.1 WHO melaporkan bahwa TB merupakan pembunuh tertinggi ke-lima di Indonesia, merengut nyawa lebih dari enam puluh enam ribu orang pada tahun 2012.2 Meskipun regime pengobatan yang telah direkomendasikan WHO memiliki efikasi yang tinggi dan tersedia secara luas, insidens TB di Indonesia masih tinggi, dengan 244 per 100.000 orang baru didiagnosis dengan TB pada tahun 2010.3 Berbagai hal mempengaruhi keberhasilan diagnosis awal dan pengobatan TB, seperti rendahnya keterlibatan pemerintah dan lembaga masyarakat, ketidakserdiaan layanan kesehatan yang memadai, ketidakpedulian terhadap status kesehatan pribadi (10), hingga kurangnya tingkat pendidikan dan pengetahuan masyarakat(8).4,5 Munculnya kasus TB multidrug-resistant (MDR) dan extensively drug-resistant (XDR) memperkeruh permasalahan. TB MDR disebabkan oleh strain Mycobacterium tuberculosis yang resisten terhadap dua dari obat-obatan lini pertama (rifampicin dan isoniazid), dan TB XDR disebabkan oleh Mycobacterium yang resisten terhadap rifampicin, isoniazid, semua fluorokuinolon, dan setidaknya satu dari tiga obatan injeksi lini kedua, yaitu kanamycin, amikacin, dan capreomycin.6,7 Pengobatan untuk TB MDR dan XDR, walaupun tersedia, lebih rumit dan lebih mahal biayanya bila dibandingkan dengan TB non-resisten, dengan tingkat kegagalan dan mortalitas yang lebih tinggi.6 Indonesia merupakan salah satu dari 27 negara yang memiliki beban TB MDR tinggi di dunia, dengan 6.800 kasus baru setiap tahun. TB MDR mencakup 2.8% kasus TB baru dan 16% kasus TB yang telah diobati sebelumnya.4 Sebagai negara dengan populasi yang tinggi, kegagalan mengontrol insidens TB—baik itu resisten ataupun non-resisten— di Indonesia dapat memengaruhi keberhasilan global dalam menyelesaikan morbiditas dan mortilitas akibat TB.7 Terlebih lagi, kegagalan mengontrol TB resisten dapat mengembalikan dunia di suatu masa di mana obat-obatan tidak lagi efektif.6 1

Rendahnya kepatuhan (poor compliance) pasien terhadap regime pengobatan sebagai salah satu faktor penghambat keberhasilan terapi TB, selain dapat meningkatkan resiko morbiditas dan mortalitas, menyebabkan resistensi obat TB.6 Sebuah studi oleh Widjanarko et al. (2009) di Jawa Tengah menemukan bahwa kebanyakan pasien tidak melanjutkan pengobatan karena sudah merasa lebih sehat, mengalami efek samping dari konsumsi obat (seperti mengeluarkan urin berwarna merah), dan/atau tidak memiliki uang.8 Ini menunjukkan bahwa pengetahuan pasien akan TB, pengobatannya, dan pentingnya mematuhi regime terapi merupakan faktor penting dalam menentukan kepatuhan pasien dan keberhasilan pengobatan TB. Hingga saat ini, belum ada studi di Indonesia yang menghubungkan pengetahuan pasien TB dengan kepatuhan pasien terhadap terapinya di tingkat nasional. Oleh sebab itu, peneliti tertarik menyelidiki asosiasi antara pengetahuan dan persepsi pasien TB mengenai penyakitnya dan tingkat kepatuhan pasien terhadap regime pengobatan TB.

1.2 Identifikasi Masalah

Rendahnya tingkat kepatuhan pasien TB terhadap pengobatan TB di Indonesia.

1.3 Pertanyaan Penelitian

Bagaimana hubungan antara pengetahuan dan persepsi pasien TB terhadap TB dengan kepatuhan pasien terhadap pengobatan TB di Indonesia?

1.4 Hipotesis

Rendahnyat tingkat pengetahuan dan persepsi pasien TB terhadap TB berkorelasi dengan tingkat kepatuhan terhadap pengobatan TB di Indonesia yang tinggi.

1.5 Tujuan Umum

2

Mengetahui hubungan antara pengetahuan dan persepsi pasien TB terhadap TB dengan kepatuhan pasien terhadap pengobatan TB di Indonesia.

1.6 Tujuan Khusus

• Mengetahui tingkat pengetahuan akan TB pada pasien yang patuh terhadap regime pengobatan TB di Indonesia. • Mengetahui tingkat pengetahuan akan TB pada pasien yang tidak patuh terhadap regime pengobatan TB di Indonesia. • Mengetahui faktor-faktor yang memengaruhi pengetahuan akan TB pada pasien di Indonesia.

1.7 Manfaat

1.7.1

Ilmu Pengetahuan Penelitian dapat memperkaya ilmu pengetahuan mengenai tingkat kepatuhan pasien

terhadap

pengobatan

TB

serta

hubungannya

dengan

tingkat

pengetahuan pasien TB dan faktor-faktor yang dapat memengaruhinya di Indonesia.

1.7.2

Peneliti Penelitian dapat memberikan informasi mengenai tingkat pengetahuan pada pasien TB di Indonesia dan hubungannya terhadap kepatuhan pasien terhadap regime pengobatan TB.

1.7.3

Layanan Masyarakat Penelitian dapat meningkatkan kesadaran masyarakat akan pentingnya kepatuhan terhadap regime pengobatan dan pentingnya meningkatkan pengetahuan akan TB, sehingga dapat membantu mencegah penambahan kasus baru TB. 3

BAB 2 TINJAUAN PUSTAKA

2.1. Tuberkulosis Tuberkulosis merupakan penyakit yang sudah ada sejak zaman purbakala. Sejak tahun 1980, penyakit tuberkulosis di negara-negara maju sudah dapat ditekan, namun penyakit ini masih merupakan masalah yang besar pada negara-negara berkembang dan tertinggal.9 Tuberculosis disebabkan oleh beberapa bakteri, diantaranya yang paling utama adalah: Mycobacterium tuberculosis, Mycobacterium bovis, dan Mycobacterium africanum. Bakteri-bakteri ini dapat menyebabkan baik tuberkulosis pulmoner maupun tuberkulosis ekstrapulmoner.9 Karakteristik dari bakteri penyebab tuberkulosis adalah bakteri non-motil yang tidak memproduksi baik toxin maupun spora dengan ukuran 2-4Âľm. Selain itu, Mycobacterium memiliki periode pertumbuhan yang lambat dengan waktu membelah selama 18 sampai 24 jam dan dapat hidup didalam sel selama waktu yang lama. Namun salah satu karakteristik yang dipakai untuk diagnosis adalah bakteri ini tahan asam (BTA) sehingga uji basil tahan asam seperti uji Ziehl-Neelsen dan Kinyoun dapat dipakai untuk mengidentifikasi genus bakteri Mycobacterium.10 2.1.1. Patogenesis dan Patofisiologi Tuberkulosis Patogenesis dari penyakit tuberkulosis melibatkan kedua faktor yaitu faktor bakteri dan faktor tubuh manusia. Pada keadaan sehat, sistem imun dapat menekan pertumbuhan bakteri ini sehingga infeksi tidak dapat menyebar, walaupun hal ini akan menyebabkan beberapa gejala TB yang tipikal seperti ditemukannya granuloma dan sel datia Langhans.9,10 Kemampuan bakteri tuberkulosis untuk menghindari sistem kekebalan tubuh disebabkan oleh karena bakteri ini dapat mencegah penghancuran bakteri normal melalui fagosom. Oleh karena itu, bakteri ini dapat hidup dan membelah di dalam sel fagosit.1

4

Selain itu, salah satu gejala dari tuberkulosis adalah pembentukan granuloma, yaitu daerah isolasi bakteri yang berisi sel datia langhans, makrofag epitelioid, dan limfosit. Pembentukan granuloma merupakan salah satu respons tubuh untuk mencegah penyebaran bakteri.9 2.1.2. Epidemiologi dan Beban Tuberkulosis Pada tahun 2015, tuberkulosis masih termasuk salah satu penyebab kematian terbesar di dunia. Sekitar 1.4 juta orang meninggal oleh karena tuberkulosis, dengan kasus baru sebanyak 10.4 juta kasus.11 Indonesia adalah salah satu negara yang memiliki prevalensi tuberkulosis tertinggi. Menurut data WHO pada tahun 2016, Indonesia merupakan salah satu negara yang menyumbang 60% kasus baru, bersama dengan India, Cina, Nigeria, Pakistan, dan Afrika Utara. Hal ini menyebabkan Indonesia menjadi salah satu negara yang ditetapkan sebagai 30 negara dengan beban tuberkulosis tertinggi di dunia oleh WHO.11 Insidens tuberkulosis di Indonesia sebanyak sekitar 1.020.000 penderita tiap tahunnya, dengan prevalensi pada tahun 2013-2014 sebesar 759 kasus per 100.000 populasi. Oleh karena itu, Indonesia menyumbang sebanyak 10% dari total kasus TB di dunia, dan 7% dari total kematian oleh karena TB.12 Prevalensi tuberkulosis MDR (tuberkulosis resisten rifampicin) di Indonesia juga masih tinggi, yaitu sekitar 2.8% dari total kasus tuberkulosis, dengan insidensi sebanyak 32 kasus setiap 1000 orang. Insidens MDR di Indonesia sekitar 69% dari total kasus MDR. Hal ini berarti insidens MDR di Indonesia masih sangat tinggi dibandingkan dengan prevalensi TB MDR.12 Selain itu, tuberkulosis merupakan salah satu penyakit yang memiliki beban ekonomi yang sangat tinggi. Diperkirakan total beban ekonomis yang disebabkan oleh tuberkulosis adalah sekitar 6.9 miliar US$, dengan beban ekonomis yang disebabkan oleh proses pengobatan sebesar 156 juta US$. Beban ini sangat tinggi dan keberhasilan pengobatan dapat berpengaruh terhadap kesehatan ekonomi Indonesia.13

5

2.2.

Pengobatan Tuberkulosis Menurut konsensus PDPI, pengobatan tuberkulosis terbagi menjadi 2 yaitu fase intensif selama dua sampai tiga bulan, diikuti dengan fase lanjutan selama empat atau tujuh bulan.14 Obat lini pertama yang digunakan adalah INH, rifampisin, pirazinamid, streptomisin, dan etambutol. Penatalaksanaan dapat dilakukan dengan menggunakan kombinasi dosis tetap (KDT) R/H/Z/E 150/75/400/275 yang disesuaikan dengan berat badan setiap hari selama fase intensif.14 Pengobatan fase lanjuan dapat dilakukan dengan menggunakan KDT R/H/Z 150/150/500mg 3 kali dalam seminggu atau kombinasi R/H 150/150mg 3 kali dalam seminggu selama empat bulan.14 Namun apabila pasien putus obat, maka dapat dilakukan uji resistensi obat antituberkulosis (OAT). Jika terdapat resistensi ganda (MDR), maka dapat digunakan obat tambahan seperti aminoglikosida, thiomides, pirazinamid, etambutol, ofloksasin, atau sikloserin sesuai dengan resistensi bakteri. Pengobatan pada penderita tuberkulosis MDR memerlukan waktu yang cukup lama yaitu 18 tahun sehingga metode Directly Observed Treatment Short Course (DOTS) sangat disarankan supaya tidak terjadi putus obat.6

2.3. Prognosis dan Komplikasi dari Tuberkulosis 2.3.1. Prognosis Tuberkulosis Tuberkulosis merupakan penyakit yang bisa diobati dengan tingkat keberhasilan yang tinggi. Namun, terapi tuberkulosis memerlukan waktu yang sangat lama, yaitu 2-3 bulan fase intensif dan 4 atau 7 bulan fase lanjutan.9 Meskipun demikian, bakteri tuberkulosis resisten sangat sering muncul akibat terapi yang tidak optimal maupun oleh karena kegagalan terapi yang disebabkan oleh putus obat. Pasien tuberkulosis kronis yang putus obat memiliki resiko yang paling tinggi untuk menderita tuberkulosis MDR.9 Selain itu, pada tahun 2006 ditemukan kasus tuberkulosis XDR atau tuberkulosis resisten ekstrim. Tuberkulosis ini didefinisikan sebagai tuberkulosis MDR yang resisten

6

terhadap salah satu flourokuinolon dan salah satu dari antibiotik suntik garis kedua yaitu amikacin, capreomycin, atau kanamycin.9 Resistensi obat sangat mempengaruhi keberhasilan terapi. Sebuah penelitian menunjukkan bahwa 62% penderita tuberkulosis MDR berhasil diobati, namun hanya 44% penderita tuberkulosis XDR yang berhasil diobati.15

2.4

Hubungan antara Pengetahuan dan Persepsi Pasien TB terhadap TB dengan Kepatuhan pasien terhadap Pengobatan Pengobatan terhadap TB telah dikenal untuk memiliki tingkat penyembuhan yang baik, namun kepatuhan pasien terhadap pengobatan yang kurang menjadikan kontrol terhadap TB dan mencapai target penyembuhannya menjadi terhambat. Kepatuhan pasien yang buruk terhadap pengobatan dapat menyebabkan terjadinya peningkatan morbiditas, mortalitas dan resistensi terhadap pengobatan.16 Usaha telah dilakukan untuk menjaga kepatuhan pasien terhadap pengobatannya, salah satu usaha yang dikenal secara global merupakan strategi directly observed treatment short-course (DOTS), di mana dalam strategi ini pasien diwajibkan untuk memiliki rekan yang secara rutin memantau dan menjaga kepatuhan pasien terhadap pengobatannya

17,18

Kepatuhan terhadap pengobatan

yang terganggu berkorelasi dengan peningkatan risiko terjadinya dari TB-MDR.19 Beberapa faktor yang dapat memengaruhi kepatuhan pasien terhadap pengobatan telah berhasil diidentifikasi, diantaranya yaitu mencakup: status sosio-ekonomi pasien seperti pendapatan yang kurang, kecanduan terhadap alkohol, ko-infeksi dengan HIV, jenis kelamin laki-laki, dan pengetahuan serta kepedulian yang kurang terhadap pengobatan TB.20-23 Beberapa alasan yang berkontribusi terhadap rendahnya pengetahuan dan kepedulian pasien terhadap pengobatan mencakup kurangnya edukasi yang diberikan oleh petugas kesehatan, kurangnya intervensi kesehatan masyarakat, tidak pernah membaca mengenai literatur yang membahas mengenai TB, dan tidak adanya anggota yang menderita TB sebelumnya.20,23 Namun, program edukasi yang hanya melibatkan penyampaian informasi kepada pasien tidak cukup, intervensi yang diberikan harus mencakup model information-motivation-behavioral skils (IMB).23 Maka dari itu, motivasi dan dukungan yang kepada pasien, baik dari pihak keluarga maupun petugas 7

kesehatan, merupakan salah satu poin penting dalam menjaga kepatuhan pasien terhadap pengobatan. Beberapa bentuk dukungan yang dapat diberikan adalah untuk mengingatkan pasien terhadap jadwal pertemuan dengan petugas kesehatan berikutnya baik secara langsung atau melalui pesan dan telefon dan mencoba kontak pasien yang tidak muncul pada saat dijadwalkannya pertemuan.24

2.4. Kerangka Konsep

8

BAB III METODE PENELITIAN 3.1.

Ruang Lingkup Penelitian Tempat: Center Utama (CU) dan semua Center Institusi (CI) yang bersedia berpartisipasi dalam penelitian ini Waktu: November 2017 sampai April 2018 Disiplin ilmu terkait: Kedokteran Pulmonologi, Kedokteran Komunitas, Mikrobiologi

3.2.

Desain Penelitian Desain penelitian ini akan menggunakan penelitian cross-sectional analitik dimana data akan diambil melalui wawancara pasien pengidap TB di PUSKESMAS dan Rumah Sakit di 15 kota di Indonesia. Data merupakan data primer menggunakan kuisioner.

3.3.

Identifikasi Variabel Variabel independen : Faktor sosioekonomi dan pengetahuan pasien terhadap penyakit TB Variabel dependen

: Kepatuhan Pasien terhadap pengobatan TB

Variabel perancu

: Jenis Kelamin, Status sosio-ekonomi, Tingkat pendidikan,

Kurangnya intervensi petugas kesehatan, Status pernikahan, Kebiasaan konsumsi alkohol 3.4.

Definisi Operasional Variabel -

Pasien yang patuh terhadap pengobatan TB melaksanakan tata laksana pengobatan TB tanpa putus obat. Pasien yang tidak patuh terhadap pengobatan TB adalah pasien yang putus pengobatan.

9

-

Faktor Sosioekonomi yang akan diteliti adalah jenis kelamin, umur, TB & BB, suku, derajat pendidikan, pekerjaan, status perkawinan (bila sudah kawin, anak berapa) dan penghasilan per bulan.

3.5.

Populasi dan Subjek Penelitian Populasi target: seluruh pasien yang terinfeksi tuberkulosis di 15 kota wilayah center institusi di Indonesia: Banda Aceh, Palembang, Jambi, Jakarta, Bandung, Yogyakarta, Solo, Semarang, Palangka Raya, Malang, Surabaya, Makassar, Kendari, Palu, Maluku.

Populasi.

Sampel penelitian: Populasi target yang memenuhi kriteria inklusi dan tidak termasuk dalam kriteria ekslkusi

3.6.

Kriteria Inklusi dan Ekslusi Kriteria Inklusi: •

Pasien yang menderita penyakit tuberkulosis paru

•

Pasien yang telah menandatangani informed consent terhadap kebersediaan menjadi subjek penelitian ini.

Kriteria Eksklusi: •

Pasien yang sudah menderita kanker paru

•

Pasien yang terkena koinfeksi HIV

•

Pasien dengan keterbatasan fisik atau mental menghambat pengisian kuisioner secara optimal. Contoh keterbatasan fisik yang dimaksud: tunanetra, kelainan jiwa.

•

Pasien yang telah diteliti oleh center instusi lain

•

Pasien yang mengisi kuisioner secara tidak lengkap.

Kriteria Dropout: Pasien yang mengisi kuisioner tidak sesuai instruksi

10

3.7.

Teknik Pengambilan Sampel Metode sampling yang digunakan adalah consecutive sampling. Besar sampel yang dibutuhkan, mengingat penelitian merupakan penelitian analitis kategorik tidak berpasangan, adalah: đ?‘?đ?›ź 2đ?‘ƒđ?‘„ + đ?‘?đ?›˝ đ?‘ƒ* đ?‘„* + đ?‘ƒ+ đ?‘„+ đ?‘›= đ?‘ƒ* − đ?‘ƒ+

+

Keterangan đ?‘?đ?›ź : 1.96 đ?‘?đ?›˝ : 0.842 đ?‘ƒ : 0.42 đ?‘„: 0.58 đ?‘ƒ* : 0.6 đ?‘„* : 0.4 đ?‘ƒ+ : 0.24 đ?‘„+ : 0.76 đ?‘› : Besar sampel Data P dan Q merupakan data dari penelitian yang dilakukan oleh Putera et al. (2015).

Besar sampel penelitian ini adalah 28.3 ≈ 30 dimana 15 sampel adalah perempuan dan 15 sampel lainnya adalah laki-laki (sesuai rasio matching).

3.8.

Instrumen Penelitian Instrumen penelitian yang digunakan adalah kuisioner untuk mengetahui sosiodemografis pasien, pengetahuan pasien terhadap infeksi tuberkulosis, dan kepatuhan pasien terhadap pengobatan TB. 11

3.9.

Cara Pengumpulan Data Setiap center institusi mengambil data dari PUSKESMAS atau rumah sakit yang mengobati pasien terinfeksi Tuberkulosis. Berikut adalah alur pengambilan data: 1. Subjek di PUSKESMAS dan rumah sakit dipilih berdasarkan kriteria inklusi dan eksklusi yang telah ditetapkan sehingga jumlah subjek memenuhi besar sampel minimal.

2. Subjek diminta untuk mengisi data demografis 3. Subjek akan diwawancarai berdasarkan kuisioner pengetahuan TB dan kepatuhan terhadap pengobatan TB. Data yang telah diperoleh kemudian dikumpulkan ke center utama untuk dianalisis.

3.10.

Rencana Analisis Data akan dianalisis dengan menggunakan software SPSS 24.0. Uji hipotesis yang akan digunakan adalah Pearsonâ&#x20AC;&#x2122;s chi square untuk dua populasi independen. Nilai p-value yang bermakna adalah p<0.05. Data sosioekonomi pasien akan dilampirkan dalam bentuk tabel.

3.11.

Alur Penelitian

12

13

Daftar Pustaka: 1. Soemantri S, Senewe FP, Tjandrarini DH, Day R, Basri C, Manissero D, et al.

Three-fold reduction in the prevalence of tuberculosis over 25 years in Indonesia.

The International Journal of Tuberculosis and Lung Disease. 2007 Apr 1;11(4):398-404.

2. World Health Organization. Indonesia: WHO statistical profile [Internet]. Geneva, Switzerland: World Health Organization; 2015 [cited 2017 Oct 31]. Available from: from http://www.who.int/gho/countries/idn.pdf?ua=1; 2015 3. Badan Penelitian dan Pengembangan Kesehatan, Departemen Kesehatan Republik Indonesia (2010) Laporan hasil riset kesehatan dasar (RISKESDAS) nasional 2010, Jakarta 4. World Health Organization. Global tuberculosis report 2016 [Internet]. Geneva, Switzerland: World Health Organization; 2016 [cited 2017 Oct 31]. Available from: http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.pdf 5. Lienhardt C, Glaziou P, Uplekar M, Lรถnnroth K, Getahun H, Raviglione M. Global tuberculosis control: lessons learnt and future prospects. Nature Reviews Microbiology. 2012 Jun 1;10(6):407-16.

6. Gandhi NR, Nunn P, Dheda K, Schaaf HS, Zignol M, Van Soolingen D, Jensen P, Bayona J. Multidrug-resistant and extensively drug-resistant tuberculosis: a threat to global control of tuberculosis. The Lancet. 2010 May 28;375(9728):1830-43.

7. World Health Organization. Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response [Internet]. Geneva, Switzerland: World Health Organization; 2010 [cited 2017 Oct 31]. Available from: http://whqlibdoc.who.int/publications/2010/9789241599191_eng.pdf

14

8. Factors that in uence treatment adherence of tuberculosis patients living in Java, Indonesia 9. Hopewell PC, Kato-Maeda M, Ernst JD. Tuberculosis. In: Broaddus VC, Mason RJ, Ernst JD, King TE, Lazarus SC, Murray JF. Murray and Nadelâ&#x20AC;&#x2122;s textbook of respiratory medicine. 6th ed. 2016; Philadelphia: Saunders Elsevier. p593-628.

10. Ellner JJ. Tuberculosis. In: Goldman L, Schafer AI. Goldman-Cecil medicine. 25th ed.

2016; Philadelphia: Saunders Elsevier. p2030-9.

11. World Health Organization. Global tuberculosis report 2016. 2016; Geneva: World Health Organization.

12. Nadda JP, Singh PK. New evidence of the tuberculosis burden in Asia demands national action. Lancet. 2016; 388 (10057): 2217-9.

13. Collins D, Hafidz F, Mustikawati D. The economic burden of tuberculosis in Indonesia. Int J Tuberc Lung Dis. 2017; 21(9): 1041-8.

14. Perhimpunan Dokter Paru Indonesia. Tuberkulosis: Pedoman diagnosis & penatalaksanaan di Indonesia [Internet]. 2006 [Diakses 1 November 2017]. Indonesia: Perhimpunan Dokter Paru Indonesia. Dapat diakses di: http://klikpdpi.com/konsensus/tb/tb.html 15. Johnston JC, Shahidi NC, Sadatsafavi M. Treatment outcomes of multidrug-resistant tuberculosis: A systematic review and meta-analysis. PLoS ONE. 2009; 4: 6914.

16. Adherence to Long-Term Therapies: Evidence for Action [Internet]. World Health Organization.

2003

[cited

1

November

2017].

Available

from:

http://www.who.int/chp/knowledge/publications/adherence_report/en/ 17. Hopewell P, Fair E, Uplekar M. Updating the International Standards for Tuberculosis Care. Entering the Era of Molecular Diagnostics. Annals of the American Thoracic Society. 2014;11(3):277-285.

18. Kapella BK, Anuwatnonthakate A, Komsakorn S, Moolphate S, Charusuntonsri P, Limsomboon P, Wattanaamornkiat W, Nateniyom S, Varma JK. Directly observed treatment is associated with reduced default among foreign tuberculosis patients in Thailand. The International Journal of Tuberculosis and Lung Disease. 2009 Feb 1;13(2):232-7.

19. Jain A, Dixit P. Multidrug resistant to extensively drug resistant tuberculosis: what is 15

next?. Journal of biosciences. 2008 Nov 1;33(4):605-16.

20. Muture BN, Keraka MN, Kimuu PK, Kabiru EW, Ombeka VO, Oguya F. Factors associated with default from treatment among tuberculosis patients in Nairobi province, Kenya: a case control study. BMC public health. 2011 Sep 9;11(1):696.

21. Burman WJ, Cohn DL, Rietmeijer CA, Judson FN, Reves RR, Sbarbaro JA. Noncompliance with directly observed therapy for tuberculosis: epidemiology and effect on the outcome of treatment. Chest. 1997 May 31;111(5):1168-73.

22. Paixão LM, Gontijo ED. Profile of notified tuberculosis cases and factors associated with treatment dropout. Revista de Saúde Pública. 2007 Apr;41(2):205-13.

23. Dick J, Lombard C. Shared vision–a health education project designed to enhance adherence to anti-tuberculosis treatment. Int J Tuberc Lung Dis 1997; 1: 181-6.

24. Liu Q, Abba K, Alejandria MM, Balanag VM, Berba RP, Lansang MA. Reminder systems and late patient tracers in the diagnosis and management of tuberculosis.

Cochrane Database Syst Rev 2008;(4):CD006594.

LAMPIRAN

Surat Informed Consent

No. Kuesioner: CI/.../...

Informed Consent Informasi Penelitian Judul: “Hubungan antara Pengetahuan dan Persepsi terhadap Tuberkulosis Paru terhadap Kepatuhan Pengobatan Anti-TB di Indonesia: Studi Multi-center” Bapak/Ibu yang terhormat, Kami adalah mahasiswa Fakultas Kedokteran AMSA Indonesia. Bersama dengan ini, kami ingin 16

memohon partisipasi Bapak/Ibu untuk penelitian kami.

Penelitian ini kami lakukan dalam upaya mengetahui hubungan antara Pengetahuan dan Persepsi terhadap Tuberkulosis Paru terhadap Kepatuhan Pengobatan Anti-TB yang dinilai dari sudut pandang bapak/ibu sebagai pasien. Hasil penelitian ini diharapkan dapat memberikan masukan kepada pemerintah untuk mengadakan evaluasi sistem kesehatan di Indonesia demi meningkatkan kualitas pelayanan bagi pasien.

Bapak/ibu akan kami berikan kertas berisi pertanyaan yang akan bapak/ibu Kami berharap pertanyaanpertanyaan berikut dapat dijawab dengan sejujur-jujurnya tanpa paksaan dari pihak manapun.

Penelitian ini tidak akan berdampak apapun pada bapak/ibu dan semua informasi akan disimpan dan kerahasiaan akan dijaga. Partisipasi bapak/ibu dalam penelitian ini sangat berharga untuk meningkatkan upaya perbaikan sistem kesehatan di Indonesia.

Pernyataan Persetujuan â&#x20AC;&#x153;Dengan ini saya bersedia menjadi responden dan berpartisipasi dalam penelitian yang berjudul â&#x20AC;&#x2DC;Hubungan antara Pengetahuan dan Persepsi terhadap Tuberkulosis Paru terhadap Kepatuhan Pengobatan Anti-TB di Indonesia: Studi Multi-centerâ&#x20AC;&#x2122; tanpa paksaan dari siapapun. Semua jawaban yang saya kemukakan bersumber dari diri saya pribadi dan saya bertanggung jawab atas jawaban-jawaban yang saya berikan.â&#x20AC;?

Nama

:

Usia

:

Nomor Telfon

:

Alamat rumah

: Hormat saya

(_____________) *Lingkari pilihan yang benar

17

Kuisioner Sosioekonomi Pasien TB Paru 1. Inisial Pasien 2. Jenis Kelamin 3. Tanggal Lahir 4. Umur 5. TB & BB 6. Suku 7. Pendidikan 8. Pekerjaan 9. Status Perkawinan (Bila sudah kawin, anak berapa) 10. Penghasilan per bulan

Kuesioner pengetahuan Pasien terhadap tuberkulosis 1. Menurut Anda, apa itu penyakit TB paru?

-

Penyakit menular yang disebabkan oleh kuman/bakteri

2. Apakah penyebab penyakit TB paru?

-

Kuman Mycobacterium tuberculosis

3. Apakah tanda-tanda seseorang terkena penyakit TB paru?

-

Batuk berdahak selama 2-3 minggu atau lebih, batuk bercampur darah, berkeringat pada malam hari tanpa kegiatan fisik

4. Bagaimana cara penularan penyakit TB paru?

-

Penularan penyakit TB paru dapat terjadi melalui batuk, bersin yang mengandung kuman TB yang terhirup orang lain

5. Apakah kebiasaan yang memperburuk kesehatan penderita TB paru?

-

Merokok, lingkungan dan kurang gizi

6. Apakah pemeriksaan yang dilakukan untuk dapat menegakkan seseorang menderita TB paru?

-

Pemeriksaan dahak, rontgen dan laboratorium

7. Berapa lama seorang penderita TB paru harus minum obat?

18

-

Minum obat selama 6 bulan dengan tahap awal (2bulan) obat diminum setiap hari dan dianjurkan dengan minum obat 3x seminggu selama 4 bulan

8. Apakah efek samping yang dapat ditimbulkan obat anti-TB? -

Warna kemerahan pada air seni (urine), tidak ada nafsu makan, mual, sakit perut, nyeri sendi dan kesemutan sampai dengan rasa terbakar

19

PCCEAMSC2018

Pre-Conference Competition East Asia Medical Students Conference

AMSA-Indonesia Bundle of Acads AMSA-UI 2017/2018

PCCEAMSC2018

Scientific Paper

Bundle of Acads AMSA-UI 2017/2018

Pre-Conference Competition East Asian Medical Studentsâ&#x20AC;&#x2122; Conference 2018

SYSTEMATIC REVIEW

Integrated algorithm of postpartum hemorrhage management in developing countries: implication for reaching worldâ&#x20AC;&#x2122;s fifth sustainable developmental goals Authors: Andrea Laurentius1 Nathasha Brigitta Selene2 Averina Geffanie Suwana3 Kresanti Dewi Ngadimin4 1Second

Year Medical Student, Universitas Indonesia, (085372724042, laurentiusandrea@gmail.com) 2Second Year Medical Student, Universitas Indonesia, (082112870839, brigitta.selene@yahoo.com) 3Second Year Medical Student, Universitas Indonesia, (08111200259, averinasuwana8@gmail.com) 4Second Year Medical Student, Universitas Indonesia, (08135206000, kresanti.dewi@gmail.com)

Asian Medical Students Association Universitas Indonesia

Introduction Postpartum hemorrhage (PPH) is known as one of the most complicated situations during delivery. It is classically defined as after-labor blood loss for more than 500 ml although newer definition has been being proposed for further clarification. It could extensively disrupt maternal physiology which normally help mothers to fully adapt with the state of postpartum. PPH has predominantly caused maternal death all over the world, especially in low resource developing countries. Prevalence of PPH in several countries over the world is summarized in the following table 1 and graph 1.

Postpartum hemorrhage has become a significant global health issue as goal in reducing maternal mortality up to 75% is included in the worldâ&#x20AC;&#x2122;s fifth Sustainable Developmental Goals (SDG).

Nevertheless, reaching this goal is difficult since the rate of maternal death in some developing countries are higher than ever before. Guidelines provided by WHO, FIGO, and ICM in preventing and treating postpartum hemorrhage do not always adhere to conditions in developing countries where the incidence of PPH is high. Diagnosis of postpartum hemorrhage before or during delivery is strictly encouraged to anticipate next steps in treating the event accordingly; however, application of advanced diagnostic tools and skilled primary care physicians towards PPH in some developing countries is not sufficiently provided due to several factors, such as uneven distribution of certified health workers across nation, limited political commitment, and inadequate financial resources. Moreover, unstandardized definition of postpartum hemorrhage diagnosis in developing countries could potentially marked errors in any data taken by hospitals for future references. Preventive actions, diagnostic examination, and prophylactic treatments of PPH are individually controlled as no clear integrated methods or algorithms are taken into practices. Improvement of management via prevention, diagnosis, and treatment for women with PPH are important challenges encountered by governments, as well as medical authorities in developing countries.1

Table 1. Prevalence of maternal death in developing countries.2-9

40 35

Prevalence of Maternal Death Worldwide

Prevalence (%)

30 25 20 15 10 5 0 Indonesia Malaysia Vietnam Central Asia

India

Maldives Sri Lanka Uganda

Latin East Asia American

Graph 1. Distribution of maternal death in worldwide developing countries.2-9 Considering any realities that maternal death in developing countries especially in low income countries is still high despite actions done by physicians, specialists, and government has come up to a proximate question. Is there any possible method involving management of PPH executed in developing countries optimally to further reduce maternal death? Elaboration of problems specifically to those aspects would not give potential solution, but observing the aspects in big picture might summon insights about integrated methods in reducing maternal mortality in developing countries. This integrated method in preventing, diagnosing, and treating postpartum hemorrhage prophylactically could offer better outcome regarding minimization of maternal death in developing countries in the world. As a result, this conjoined method could be optimally utilized as it is low-cost and practical.

Material and Methods Searches on PubMed database were made from 2nd October 2017 to 25th October 2017 in order to find potentially relevant journals for this systematic review. Types of study such as cohort studies, trials, cross-sectional studies, systematic reviews, and meta-analyses are eligible. Four separate searches have been done to be reviewed systematically using criteria of exclusion and inclusion in similar fashion.

Keywords used were “prevalence”, “maternal death”, “postpartum hemorrhage”, “cause”, “education”, “training”, “diagnostic”, “tools”, “active management of third stage of labor”, “carbetocin”, and “efficacy”. Exclusion criteria are studies that are not relevant after title and abstract screening, studies older than 15 years old, as well as data inadequacy. As much as 681 journals are finely selected into only 76 journals as they are the most closely associated ones.

Studies included for prevalence and cause of PPH

Studies included for second line of management

Studies included for the first line in management of PPH

Studies included for third line of management

Figure 1. Systematic methods in searching and selecting relevant literatures in database using PRISMA criteria.

(N=8)

(N=14)

Results and Discussion Postpartum hemorrhage should be etiologically recognized for its wide implications towards mothers and neonates. To understand the major risk factors that drive PPH, pointing causes of PPH could be made for constructing the method comprehensively. Frequent causes of postpartum hemorrhage comprise of uterine atony, genital tract trauma, retained placenta, coagulation defect, uterine inversion, and abnormal implantation of the placenta.1,10 Uterine atony or inadequate uterine contraction constitutes 70% major risk factors of PPH. Uterine atony is additionally reinforced by uterine overdistension, fetal macrosomia, or multifetal gestations.1 Furthermore, genital tract trauma comprises the second most probable cause of PPH which may result from lacerations of the cervix, episiotomy, or uterine rupture. Iatrogenic trauma such as cesarean delivery and instrumental delivery might also increase the risk of PPH.1 Retained placenta and clotting prevent adequate uterine contraction during delivery, inducing the probability of intrauterine hemorrhage.1 Other placental disorders, such as placenta previa and placenta accerata, widely corrupt the normal plane of placenta via overlying the internal cervical orifice and invading myometrium in uterus respectively.1,10 Special cases in either inherited or acquired hemostatic defects, as well as pre-eclampsia, alerts obstetrician and doctors to carefully assess maternal condition before delivery.11 For instance, intrauterine fetal demise with prolonged retention of a dead fetus, massive blood loss, amniotic fluid embolism, and sepsis, thrombocytopenia, von Willebrand disease are considered to be promoters of PPH risk factors.1,10,11 Table 2. The underlying causes of postpartum hemorrhage from the most to the least common ones.1,12

Clearly, suppression of postpartum hemorrhage incidence yields positive correlation with professional management of its underlying causes. Since developing countries often possess low-skilled workers and financial resources for health sectors, they are more susceptible to the incidence of the event. Thus, managerial measures in tackling its risk factors ought to be taken in facing the problems in order to minimize the events, as well as medical expenses in which the countries spend.

Management of risk factors in reducing postpartum hemorrhage Preventive actions towards health workers and pregnant mothers via simulation and education respectively: primary line of management Simulation training for health personnel about PPH has been shown to improve the implementation of ICM/FIGO guideline in active third stage management.13 However, skilled health personnel are rare to find in even in developing countries.14 Furthermore, healthcare provider in underdeveloped countries has suboptimal knowledge of PPH risk, factors, diagnosis, and etiologies.15 Therefore, an effort to produce more skilled worker must be taken to overcome this problem. For example, training is required to address low level of knowledge of misoprostol registration and uses in low resource places.16 Training to healthcare provider especially in underdeveloped countries is needed as a low cost solution in preventing PPH incidence especially in low income countries.17 Simulation training program has proven to improve performance and skills about PPH.18 PETRA (Perinatal Emergency Team Response Assessment) scale is one of the methods in assessing team performance during obstetric crisis simulation. It is a valid and reliable tool to assess team dynamics to face obstetrics crises.19 Data consisting training intervention and its results from several journals are summarized in the following table 3.

Table 3. Results of training intervention as preventive actions towards management postpartum hemorrhage. 20-27. tool to assess team dynamics to face obstetrics crises.19 Data consisting training intervention and its results from several journals are summarized in the following table 3.

Simulation-based training for either emergency maternal life support or delivery service substantially depressed the level of postpartum hemorrhage incidences. Considering the huge advantage of minimizing maternal death in a financial efficient manner, low-resource developing countries would be able to achieve the SDG goals in higher probability. Additionally, trainees consisting of primary health providers, physicians, or obstetricians are readily deployed to their maximal effort in caring pregnant mothers. Training-based educations done as preventive actions provide more permanent skills towards health personnel in managing the events. Effective distribution of prophylactic gestational drugs requires another educative action for mothers as unmonitored administration might cause maternal side effects, or even fetal abortion. Regarding effective reduction of PPH-associated death, secondary line of management besides preventive actions is required; that is proper antepartum diagnosis in detecting risk factors.

Prior diagnosis of pregnant mothers visiting for antenatal care: secondary line of management Regarding the ultimate mission of WHO in accomplishing the fifth Millennium Developmental Goal, that is the reduction of maternal death up to 75%, several actions should be done in the first place to achieve the goal at both developed and developing countries in the world.28 Actions of public health in accordance with maternal and neonatal health will be the chosen representatives. Education and preventive orders towards pregnant mothers, as well as reproductive female adults, serve as primary care system to minimize any risk factors related to postpartum hemorrhage. To further reduce mortality and morbidity of pregnant women due to postpartum hemorrhage, rapid and accurate antepartum diagnostic tools are necessary to decrease the complication. WHOâ&#x20AC;&#x2122;s attempts to assess every maternal-

fetal healthcare system in detecting PPH suspicions in the world have come to the usage of maternal near miss rate and mortality index.29 WHO has created sensitive algorithms in recording any cases related to maternal near miss death following disease, medical intervention, and organ dysfunction.

Emphasizing the complication of organ dysfunction and lowering the threshold in transfusing blood during labor have caused higher detection in maternal near miss records since they can be used in varying patientsâ&#x20AC;&#x2122; conditions.30 Data of maternal near miss and mortality index in hospitals or healthcare system in several countries are summarized in the following table 4 and graph 2.

Table 4. Maternal near miss rate and mortality index in several countries for the required improvements.31-39

WHO's Maternal-Fetal Healthcare System Assessment 25 20 15 10 5

**

0 Tanzania Rwanda Uganda

Iraq

India

Egypt

Maternal Near Miss Rate (per 1000 live births)

Malaysia Brazil I

Brazil II

Syria

Mortality Index (%)

Graph 2. Maternal-fetal healthcare assessment in developing countries via WHOâ&#x20AC;&#x2122;s guidelines of maternal near miss rate and mortality index.31-39 (**) sign means no available data.

Healthcare system in several developing countries has not yet satisfyingly fulfill the criteria of maternal death reduction target, which is below 5% index. This view infers the low-quality of maternal health service provided in hospitals. In that case, hospitals or primary care centers in developing countries need to utilize much simpler, practical, and low-cost diagnostic methods.

Proper definition of postpartum hemorrhage should be strictly determined since it would offer as potential data in the future regarding its diagnosis. Postpartum hemorrhage is classically defined as loss of blood after or during labor for more than 500 ml. Nevertheless, this amount of lost blood may be tolerated by some women, in some cases, since the number was a cut-off where postpartum hemorrhage often causes maternal death.40 A new definition proposed for this condition would be the loss of blood in labor which reduces the hemoglobin concentration up to more than 2 g/dl or 10% of total Hb.40,41 Ensuring the usage of hemoglobin parameter would ignore the error of visual estimation. Qualitative visualization of blood loss estimation in postpartum hemorrhage is low in accuracy and precision.42 To minimize the counter-effect that hemoglobin examination consumes time, low-cost blood pressure and shock monitoring machine could be utilized for any emergency situations regarding hemorrhage, establishing shock index in the machine as basis of treatment.43 Table 5. Ultrasound imaging usage in diagnosing pre-postpartum hemorrhage according to criteria.5665

Early detection of risk factors is essential in diagnosing postpartum hemorrhage. History medical records, uterine imaging, and peripheral blood tests provide significant data in reinforcing the detection.28,44-48 Pre-eclampsia, 44.5% of postpartum hemorrhage risk factors (OR = 1.53, 95% CI 1.461.6), can be examined via urinary adipsin rapid test, plasma uric acid, serum minerals, growth factors, and umbilical ultrasonography.28 Urinary adipsin test provides accurate diagnostic value of preeclampsia with sensitivity and specificity reaching 94.15% and 98.2% respectively. Its accuracy is 97.55%, and it is consistent with kappa value of 0.93 compared with gold standard.49,50 Elevated plasma uric acid or decreased serum zinc-copper are potential signs of pre-eclampsia along with gestational hypertension reading.51-53 VEGF and PIGF analysis in plasma also explains direct proportional to preeclampsia, indicating systemic inflammation during the condition.54 History of bleeding disorders, especially vWD type III, no antenatal care, and previous cesarean delivery (OR = 3) could initiate steps towards diagnosis of postpartum hemorrhage as they increase the risk of it.45-47,55 Further examination required to determine probability of future hemorrhage relies on low-cost ultrasound imaging technique.48 Utilization of ultrasound imaging in establishing criteria for postpartum hemorrhage diagnosis is included in the following table.

Ensuring proper diagnosis in antenatal care for pregnant women would dramatically limit the number of maternal death secondarily due to PPH. Cost-efficient methods in detecting PPH risk factors consisting familial disease history, peripheral blood examination, as well as sonographic assessments might offer inexpensive financial expenses in developing nationwide without altering their diagnostic accuracy. Not only direct risk factors discoveries are important, but also conventional medical definition of postpartum hemorrhage should be elaborated to the newer one to minimize bias in recording any of the events for future data. After management of its risk factors via diagnosis, tertiary line of management as part of goals in reducing maternal death would be uterotonic drugs for prophylaxis.

Active management of the third stage of labor in situational-effective state via prophylactic treatment: tertiary line of management As a matter of fact, prevention of postpartum hemorrhage widely utilizes the Active Management of the Third Stage of Labor (AMTSL) which includes the prophylactic administration of uterotonic agents, controlled cord traction and uterine massage is recommended by WHO, FIGO, and ICM. Prophylactic administration with uterotonic substances, such as misoprostol, right before the predicted day of delivery would significantly protect women from PPH. Oxytocin is used as the first line of treatment due to its efficacy and few contraindications. However in low resource settings, the use of oxytocin is not feasible due to cost, and heat instability. Therefore, alternative uterotonic agents that could provide equal or greater results at a more efficient price point should be considered. Furthermore in low resource settings where there is an absence of uterotonics, controlled cord traction and uterine massage should be evaluated to analyze their effectiveness to provide better outcomes.

The route of oxytocin administration is important when it is the only intervention available; in which intravenous administration reduced hemorrhage risk by 76% compared to intramuscular administration (OR = 0.24, 95% CI 0.12-0.50). However in a condition where no uterotonic prophylaxis is available, controlled cord traction reduced post-partum hemorrhage nearly 50% (OR = 0.53, 95% CI 0.42â&#x20AC;&#x201C;0.66) compared to no AMTSL components.66 As opposed to the AMTSL regimen in FIGO guidelines, uterine massage is associated with insignificant reduced blood loss of 0.1% to oxytocin administration alone and increased risk of post-partum hemorrhage. Therefore, it should be excluded.66-68 Oxytocin is currently the golden standard for the prevention and management of PPH, however it is not heat stable as it loses it potency in field conditions especially tropical countries. 69 Oxytocin must be stored in controlled room temperature or refrigerated, therefore it is an impractical intervention in low resource settings where there is limited access to refrigeration. Carbetocin is a synthetic agonist analogue of oxytoxin, it induces a prolonged uterine response and is a stable molecule.70 Carbetocin is associated with lower mean blood loss of 34 ml than oxytocin, blood loss exceeding 500 ml was lowered from 18.4% to 25.8%, and fewer patients required additional uterotonics with 45.5% to 33.5% in oxytocin.71,72 Consequently, reductions in PPH rates and retreatments lead to the incremental cost effectiveness of carbetocin of US$278.70.73

The current formulation of carbetocin requires refrigeration, however a room temperature stable (RTS) variant of carbetocin is recently developed by Ferring Pharmaceuticals partenering with WHO.74 They have developed a new RTS carbetocin (Pabal) that have been approved by the EU Mutual Recognition Procedure. Pabal could be stored up to 300C with a shelf life of 24 months and 75% humidity, which could remove the necessity of refrigeration where it may not be available in low-income countries.75 A randomized trial of 30,000 women vaginally delivering in 10 countries on carbetocin RTS is currently being conducted to assess its non-inferiority against oxytocin.76 Health care personnel trained to perform safe intravenous and intramuscular administration of prophylactic uterotonic are not readily available in low resource countries. Therefore, a more practical alternative is the sublingual misoprostol 600 Îźg. However, its efficacy, and side effects against other uterotonics should be evaluated. Misoprostol is inferior to both oxytocin and carbetocin. Additionally shivering and fever are the most common side effects of misoprostol usage. 77,78 Using misoprostol in a community setting instead of no treatment in a chort of 1000 women would result in 22 preventable PPH cases but an additional 130 women experience shiver and 42 women with fever. However it is more cost effective compared to other prophylaxis with cost savings up to US$533. Although not the most preferable, by weighing the efficacy and the cost effectiveness of misoprostol, it is an effective and cost saving choice when there is no oxytocin available due to lack of skilled birth attendants.78 Integrated algorithm for management of postpartum hemorrhage in developing countries Suppose that each separated method in managing PPH is combined into a single view of major algorithm would serve as basis for health sectors in evaluating their performance. Initial modification of previous single method used internationally could finally conform with the condition of worldâ&#x20AC;&#x2122;s developing countries. In this case, management of PPH might comprehensively be applied in many confounding situations, like low-skilled health workers, financial resource depression, and availability of health workers or physicians in care centers.1-3 The first line in the management of PPH includes risk factors prevention comprising fundamental obstetrics training based on simulations or scenarios for health workers and education of consuming misoprostol for mothers independently of physician availability in isolated area.18-27 Reinforced skills and knowledge of care providers would help them in confidently managing PPH event.22-25 Primary line in managing PPH would not be enough to reduce maternal death as PPH may suddenly appear as internal risk factors are not detected early. Overcoming this problem would be suited best with application of prior diagnosis for the missed risk factors alleviation in the beginning. Diagnosis in antenatal care for pregnant women is divided into family history analysis for certain inherited diseases, peripheral blood tests to serologically discover any anomalies during pregnancy, and uterine imaging via ultrasonography.52-60 Blood serology test and uterine imaging could serve as either complement or substitutive examinations alternatively. Corrected definition of postpartum hemorrhage should be proposed for more valid data regarding of PPH event in hospitals since their medical records are often used for incidence and prevalence calculation. 40,41 Any suggesting components that increase the probability of PPH have to be treated retrogradely with first line of management if mothers are still in pregnant state. Third line of management is applied only for mothers that are going to deliver their babies. Careful assessments of mothersâ&#x20AC;&#x2122; condition according to the existence of major PPH risk factors must be done during the third line of management for correct uterotonic administration and cord traction in accordance with AMTSL.71-73, 75, 76 Uterotonic administrations are adaptively chosen regarding to conditions, except misoprostol for unskilled workers in doing both IV and IM injections.77,78 Algorithm for comprehensive management of PPH in developing countries is pictured in the following figure 2

AMTSL

Figure 2. Integrated algorithm in reducing PPH risk factors through three lines of management.3-8, 2025, 51-62, 70-78

Conclusion High prevalence of maternal death in developing countries in the world suggests the inadequacy of maternal health services in hospitals. Low-quality associated healthcare in these countries could be suspected for other sub-nation causes, such as lack of health workers attendance, unskillful physicians and obstetrics in treating PPH, limited governmental actions in improving maternal health sectors, and low financial resources. This condition has encouraged unification of separated and modified PPH management into single algorithm fundamentally proposed for developing countries. Maternal education and health worker training based on preventive actions are first line of management in reducing the incidence of PPH. Extra precautions for any risk factors silently occur in mothers are frequently done after prior diagnosis in antenatal care, such as history taking, blood tests, and uterine imaging. These could provide basic information to further assess the probability of mothers suffering PPH. Last line of management would be prophylactic administration of uterotonic and controlled cord traction. Associating all three lines of management in a single algorithm to reduce incidence of PPH might give huge picture of how developing countries can apply this integrated method into their problem in health sectors. Therefore, hope that developing countries could eventually accomplish the fifth sustainable developmental goal (SDG) will be realized in the future.

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42. Parayre L, Riviere O, Debost A, Lemery D, Vendittelli F. Reliability of Student Midwives' Visual Estimates of Blood Loss in the Immediate Postpartum Period: A Cross-Sectional Study.

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43. Nathan H, Hezelgrave N, Ayadi A, Seed P, Butrick E, Miller S, et al. Development of the Algorithm Incorporated into A Low Cost Vital Signs Monitor to Detect Pre-eclampsia and Shock. International Journal of Gynecology & Obstetrics. 2015;5(94):94.

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47. Durocher J, Mauer A, Dzuba I, Tarnagada M, Coller B, Winikoff B. Bleeding after Childbirth: Can a bleeding history questionnaire help identify women at risk of excess blood loss postpartum? International Journal of Gynecology & Obstetrics. 2015;5(489):e192.

48. Rulisa S, Rurangwa T, Lewis K, Small M. Point of Care Ultrasound Used for the Evaluation of Bleeding in Pregnancy in a Tertiary Care Hospital in Rwanda. International Journal of Gynecology & Obstetrics. 2015;5(126):104.

49. Peng B, Zhang L, Yan J, Qi H, Zhang W, Fan L, et al. Assessment of the diagnostic value of a urinary adipsin rapid strip test for pre-eclampsia: A prospective multicenter study. Journal of Obstetrics and Gynaecology Research 2017;43(1): 30-3.

50. Wang T, Zhou R, Gao L, Wang Y, Liu X, Zhang L. Clinical assessment of the specificity of an adipsin rapid test for the diagnosis of pre-eclampsia. Hypertension in Pregnancy 2016;35(3): 420-5.

51. Azzo N, Rasheed H, Saleem A, Hamdani I. Pregnancy Outcomes Linked to Increased Uric Acid in Pre-Eclampsia. International Journal of Gynecology & Obstetrics. 2015;5(447):e181.

52. Onyegbule O, Udigwe G, Okolie V, Ejelonu U, Iheukwumre B, Onumajulu C. Evaluation of Serum Levels of Copper and Zinc among Pre-eclamptic and non-pre-eclamptic women at Nnamdu Azikiwe University Teaching Hospital, Nnewi, and Nigeria. International Journal of Gynecology & Obstetrics. 2015;5(453):e182.

53. Giorgi VS, Witkin SS, Bannwart-Castro CF, Sartori MS, Ramao-Veiga M, Borges VTM. Elevated circulating adenosine deaminase activity in women with pre-eclampsia: association with pro-inflammatory cytokines production and uric acid levels. Pregnancy Hypertension 2016;6(4):400-5.

54. Spyroulis C. Pre-Eclampsia. Can We Predict or Prevent It? Literature Review. International Journal of Gynecology & Obstetrics. 2015;5(466):e185.

55. Govorov I, Lofgren S, Chaireti R, Holmstrom M, Bremme K, Mints M. Postpartum Hemorrhage in Women with Von Willebrand Disease: A Retrospective Observational Study Plos One 2016 10;11(10).

56. Gondo S, Urushiyama D, Yoshizato T, Kora S, Maehara M, Kondo H, et al. The successful detection of postpartum unruptured vaginal pseudoaneurysm using ultrasonography: a case report. SpringerPlus 2014 08;3(1):1-6.

57. Pan X, Wang Y, Zheng Z, Tian Y, Hu Y, Han S. A Marked Increase in Obstetric Hysterectomy for Placenta Accreta. Chin Med J 2015 Aug 20;128(16).

58. Hemorrhage; Studies from Nagoya University Add New Findings in the Area of Hemorrhage (A Novel Approach to Detecting Postpartum Hemorrhage Using Contrast-Enhanced Ultrasound). Health & Medicine Week 2017 Apr 21:9949.

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60. Adkins K, Minardi J, Setzer E, Williams D. Retained Products of Conception: An Atypical Presentation Diagnosed Immediately with Bedside Emergency Ultrasound. Case Reports in Emergency Medicine 2016.

61. Oba T, Hasegawa J, Sekizawa A. Postpartum ultrasound: postpartum assessment using sonography. Journal of Maternal-Fetal and Neonatal Medicine 2017;30(14): 1726-9.

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65. Scribner D, Fraser R. Diagnosis of Acquired Uterine Arteriovenous Malformation by Doppler Ultrasound. Journal of Emergency Medicine 2016;51(2):168-71.

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Carbetocin versus oxytocin for prevention of postpartum haemorrhage: a randomised controlled trial. The Lancet. 2014 Feb 26;383:S51.

72. Attilakos G, Psaroudakis D, Ash J, Buchanan R, Winter C, Donald F, et al. Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial. BJOG: An International Journal of Obstetrics & Gynaecology. 2010 Jul 1;117(8):929–36.

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Pre-Conference Competition East Asian Medical Students’ Conference 2018 ABSTRACT

Integrated algorithm of postpartum hemorrhage management in developing countries: implication for reaching world’s fifth sustainable developmental goals Andrea Laurentius1 Nathasha Brigitta Selene2 Averina Geffanie Suwana3 Kresanti Dewi Ngadimin4 1Second

Year Medical Student, Universitas Indonesia, (085372724042, laurentiusandrea@gmail.com) 2Second Year Medical Student, Universitas Indonesia, (082112870839, brigitta.selene@yahoo.com) 3Second Year Medical Student, Universitas Indonesia, (08111200259, averinasuwana8@gmail.com) 4Second Year Medical Student, Universitas Indonesia, (08135206000, kresanti.dewi@gmail.com)

Aim The purpose of this study is to evaluate the current preventive measures, diagnostic methods, and AMTSL guidelines from WHO, FIGO, and ICM to produce an integrated algorithm that would best accommodate the low health quality in developing countries, hoping that they could reduce maternal death up to 75%.

Background Postpartum hemorrhage becomes a significant global health issue as reducing 75% of maternal mortality is included in the world’s fifth Sustainable Developmental Goals (SDG). Guidelines provided by WHO, FIGO, and ICM in managing hemorrhage do not always adhere to conditions in some developing countries. Thus, improvement of management with PPH are important challenges encountered by governments and medical authorities. Possible method involving management of PPH executed optimally in these countries is raised as ultimate question.

Material and Methods Search engine PubMed was used to search for trials that assessed the prevalence, preventive actions, diagnosis, and prophylactic uterotonics of postpartum hemorrhage. Exclusion criteria are studies exceeding the last 15 years, irrelevant topics and data, and non-English journal.

Results Postpartum hemorrhage constitutes for the major causes of global maternal death. Each separated method, comprising preventive measures, early diagnosis, and prophylaxis administration, in managing PPH is combined into a single view of major algorithm would serve as basis in evaluating health sectorsâ&#x20AC;&#x2122; performance. Initial modification of previous single method could finally conform with the condition of worldâ&#x20AC;&#x2122;s developing countries. In this case, integrated algorithm in PPH management could be applied in many confounding situations of developing countries for future goals in SDG.

Conclusion High prevalence of maternal death in developing countries in the world suggests the inadequacy of maternal health services in hospitals. This condition has encouraged unification of separated and modified PPH management into a single algorithm fundamentally proposed for developing countries, consisting of preventive actions, antenatal care examination for prior diagnosis, and AMTSL drug prophylaxis.

PCCEAMSC2018

Scientific Poster

Bundle of Acads AMSA-UI 2017/2018

Postpartum Depression and its Association with Ante Natal Care and Quality of Sleep: A Crosssectional Study Almira Ramadhania, Brian Mendel, Angga Wiratama Lokeswara, Alice Tamara Universitas Indonesia

Background Postpartum depression (PPD) is very common nowadays and related with adverse infant and maternal outcomes. In Indonesia alone, the prevalence of PPD was 2.32% (440/18,937). Sleep disturbance is one of the emerging contributors to PPD. Untreated PPD could effect motherâ&#x20AC;&#x2122;s health and interfere with her ability to connect with and care for her baby. In theory, Ante Natal Care (ANC) was designed to encompass, not only clinical and laboratory examinations for the mothers, but also the mental health of the mother. None of the materials involve in ANC consist of psychological assessment, and no particular attention is exclusively given for the psychological well-being of the mothers. This means that any potential distress to the mothers may not surface or be expressed clearly by the mothers.

Objective The study has 2 main objectives: 1. To show the correlation between the current Indonesian ANC with PPD 2. To show the correlation between PPD and sleep deprivation

Method 107 postnatal women (until 6 months), collected by consecutive sampling method, participated in cross sectional study using Edinburgh Postnatal Depression Scale (EPDS) to predict PPD and Pittsburgh Sleep Quality Index (PSQI) to correlate PPD to maternal sleep quality.

Result Our findings showed no significant correlation between ANC and PPD (p=0.13) while distressing the relationship between PPD and sleep quality (p<0.0001). This indicates that ANC may not be significant to prevent the development of PPD while PPD is shown to have close relation with poor sleep quality.

Conclusion Early assessment of maternal psychological well-being using mental health assessment tool in ANC is important to reduce further complication which might arise from PPD. Keyword: Ante Natal Care, Postpartum Depression, Postnatal, Sleep Quality

Pre-Conference Competition East Asian Medical Students’ Conference 2018 ABSTRACT

Integrated algorithm of postpartum hemorrhage management in developing countries: implication for reaching world’s fifth sustainable developmental goals Andrea Laurentius1 Nathasha Brigitta Selene2 Averina Geffanie Suwana3 Kresanti Dewi Ngadimin4 1Second

Year Medical Student, Universitas Indonesia, (085372724042, laurentiusandrea@gmail.com) 2Second Year Medical Student, Universitas Indonesia, (082112870839, brigitta.selene@yahoo.com) 3Second Year Medical Student, Universitas Indonesia, (08111200259, averinasuwana8@gmail.com) 4Second Year Medical Student, Universitas Indonesia, (08135206000, kresanti.dewi@gmail.com)

Aim The purpose of this study is to evaluate the current preventive measures, diagnostic methods, and AMTSL guidelines from WHO, FIGO, and ICM to produce an integrated algorithm that would best accommodate the low health quality in developing countries, hoping that they could reduce maternal death up to 75%.

Background Postpartum hemorrhage becomes a significant global health issue as reducing 75% of maternal mortality is included in the world’s fifth Sustainable Developmental Goals (SDG). Guidelines provided by WHO, FIGO, and ICM in managing hemorrhage do not always adhere to conditions in some developing countries. Thus, improvement of management with PPH are important challenges encountered by governments and medical authorities. Possible method involving management of PPH executed optimally in these countries is raised as ultimate question.

Material and Methods Search engine PubMed was used to search for trials that assessed the prevalence, preventive actions, diagnosis, and prophylactic uterotonics of postpartum hemorrhage. Exclusion criteria are studies exceeding the last 15 years, irrelevant topics and data, and non-English journal.

Results Postpartum hemorrhage constitutes for the major causes of global maternal death. Each separated method, comprising preventive measures, early diagnosis, and prophylaxis administration, in managing PPH is combined into a single view of major algorithm would serve as basis in evaluating health sectorsâ&#x20AC;&#x2122; performance. Initial modification of previous single method could finally conform with the condition of worldâ&#x20AC;&#x2122;s developing countries. In this case, integrated algorithm in PPH management could be applied in many confounding situations of developing countries for future goals in SDG.

Conclusion High prevalence of maternal death in developing countries in the world suggests the inadequacy of maternal health services in hospitals. This condition has encouraged unification of separated and modified PPH management into a single algorithm fundamentally proposed for developing countries, consisting of preventive actions, antenatal care examination for prior diagnosis, and AMTSL drug prophylaxis.

Abstract

Maternal Factors Associated with Preeclampsia among Asian: Systematic Review of Large Cohort Studies

Kristian Kurniawan*, Fabiola Cathleen, Christine Lieana, Adriana V Miranda Universitas Indonesia *kristian.k9027@gmail.com

Background: Maternal mortality is still a major problem in developing countries.

World Health Organization estimates that the countries’ Maternal Mortality Rate (MMR) reaches 239 per 100.000 live births in 2015. It is very high compared to MMR in developed countries, which is as low as 12 per 100.000 live births. 25% of the problem is accounted to preeclampsia.

Objective: This paper aims to identify factors associated with preeclampsia amongst Asian in order to increase awareness and preeclampsia screening quality.

Material and method: 6133 records were found through Pubmed database searching. We then eliminate publications that did not meet our inclusion criteria (n = 6037). Cohort studies were chosen as they are able to represent pregnancy, a ninemonth process. There are 96 full text articles retrieved and assessed for eligibility: 15 of which are included in the study after assessments using exclusion criteria.

Results: 375.622 participants from 15 studies were included. STROBE Statement was used to assess the included cohort studies for systematic review to improve the quality of reporting. With the score of 20.4 out of 22, Li X, et al. 2015 becomes the best study. The studies show that risk factors of preeclampsia Maternal BMI and history of gestational hypertension and preeclampsia is risk factor of preeclampsia most discussed and problematic in Asia. Risk factors with highest odd ratio are pregestational obese (OR: 7.85); chronic hypertension (OR: 7.174); and previous history of gestational hypertension or preeclampsia (OR: 8.85), respectively. Weight gain below IOM in overweight pre-gestational weight (OR: 0.76), Isolated anti TPO antibody, normal BMI, BPD >90 (OR: 0.86), maternal weight gain <10kg and maternal weight gain ≥ 16 kg (OR:0.6) are shown as protective factors of the condition.

Conclusion: This systematic review proves the role of maternal BMI (overweight and obese), inappropriate maternal weight gain and history of pre-gestational hypertension and preeclampsia as risk factors commonly found amongst Asian.

Other risks of the problem include maternal age, mother’s education, mother activity, diabetes mellitus and hypothyroidism. The knowledge is aimed to improve the quality of preeclampsia screening and awareness.

PCCEAMSC2018

Videography and White Paper

Bundle of Acads AMSA-UI 2017/2018

Joint Effort by Healthcare System, Healthcare Personnel and Pregnant Individuals in Preventing Maternal Mortality Clara Menna, Fianti Ratna Dewi, Gabriella Anindyah, Priscilla Aya Maheswari Subroto Universitas Indonesia Indonesia Video Access: https://drive.google.com/open?id=0B3e-zrNBN_dHTWhsOVRzNm9CWTg

Introduction Current Status Maternal mortality continues to be the number one overlooked problem in the world by both physicians and the government, especially in developing countries. According to World Health Organization, 99% of maternal deaths occur in developing countries (1), a feat that is no exception for Indonesia, having a maternal mortality rate as high as 305 deaths per 100,000 live births in 2015 (2). Although this is not an updated number (as the next survey will only be held throughout 2017), this has shown that Indonesia had failed one of United Nations’ Millennium Development Goals of 102 deaths per 100,000 live births in 2015. Not only does this reflect Indonesia’s healthcare status, but also underlies other problems in Indonesia.

The impact of high maternal mortality rate in Indonesia is seen in the increase of burden held by the Indonesian government. This includes the high number of orphans in Indonesia reaching 3.2 million people in 2013 according to a comprehensive research by Yatim Mandiri. This correlates to Indonesia’s high maternal mortality rate, as more dying mothers mean that more children are born without a mother.

This can further impact the upbringing quality of Indonesian children, whom without a mother lack a certain aspect in their lives that can affect their individuals, with problems such as greater criminal rates and relative poverty rate lingering at 11.1% in 2015. (3) Context Indonesia’s Ministry of Health stated that in 2013, the causes of maternal mortality includes postpartum haemorrhage (30.3%), hypertension (27.1%), infection (7.3%) and others (35.5%)(4). Two major etiologies of maternal mortality are considered emergency situations during labour. In Indonesia and other developing countries, many cases of delivery are located in primary health facilities, assisted by

physicians or midwives. Not all of these medical personnels have successfully done the right treatment for emergency situations, even though algorithms have been made(5). Moreover, patients with complicated delivery that requires adequate facility that is not provided in the primary health care must be referred to a nearby hospital. In many cases, hospitals are fully occupied that these patients are not treated instantly.

Patients will then be left untreated and possess greater risks of death. To overcome this, medical personnel’s competency needs to be improved and hospital referral systems must be optimized.

In addition to the role of health care in reducing maternal mortality, pregnant women shall also play important roles in keeping good health of their pregnancy by increasing their awareness of symptoms regarding possible labour complications. Therefore, there needs to be a joint effort from both healthcare system and pregnant individuals to reduce maternal mortality due to labour complications.

Key Objectives & Solutions This white paper highlights the key issues of high maternal mortality rate - prevention by joint effort of healthcare system, healthcare personnel, and pregnant individuals. The objectives proposed in this white paper are, ●

Objective 1: Improving maternal health during pregnancy to prevent possible complications that can lead to increased mortality risk during childbirth

●

Objective 2: Improving maternal care during childbirth

Objective 1 : Improving maternal health during pregnancy to prevent possible complications that can lead to increased mortality risk during childbirth ●

Increasing mothers’ awareness of possible complications

The Problem Antenatal care is recommended for pregnant women in providing regular check ups and to prevent potential health problems during pregnancy. Mothers who attend for antenatal care are made aware of their condition, but mothers who don’t become clueless about their health condition. For instance, a woman who never goes to antenatal care suddenly feels headache, nausea, and keeps on vomiting. She finally goes to a healthcare facility to check her condition. She has high blood pressure and was diagnosed of eclampsia. This stage of detection is already too late and can cause higher risk of mortality during

labour. A condition as such could have been prevented, but many mothersâ&#x20AC;&#x2122; lack of awareness and compliance to go for antenatal care put them at risk of labour complications. With support from Institution of Social Insurance Administrator (Badan Penyelenggara Jaminan Sosial) in providing health insurance for Indonesian, healthcare is more readily available to people and antenatal visits have increased. However, in rural areas in Indonesia, such as Papua, West Papua, East Nusa Tenggara, the coverage of antenatal visits is still low, approximately only 50-60% of pregnant women (6).

Antenatal visits correlates to a decline in maternal mortality rate in Indonesia by monitoring health condition of pregnant women(10). However, some pregnancy complications might show symptoms that mimic the physiologic changes in pregnancy, such as headache, nausea, and vomiting. When experiencing this, mothers tend to be ignorant and refuse to consult a healthcare personnel. Mostly, only the exacerbation of symptoms will bring them to healthcare facilities, thus they could be diagnosed during the late phase of disease in pregnancy. This problem of late detection is again due to the lack of awareness of pregnant women regarding symptoms of pregnancy complications. Thus, this can further causes high maternal mortality during childbirth despite of regular antenatal visits(7).

Recommendation To further raise Indonesian mothersâ&#x20AC;&#x2122; awareness of their health during pregnancy, we propose a simple, yet effective, checklist that highlights the symptoms of possible pregnancy complications. This checklist is to be installed on large banners and billboards, as well as printed on leaflets and posters in areas still lacking antenatal visits. The checklist content includes symptoms along with possible outcomes of pregnancy complications, which are its impacts to maternal and neonatal health and mortality.

Objective 2 : Improving maternal care during childbirth â&#x2014;?

Improving efficacy of referrals during emergency cases that could lead to maternal death

The Problem There are many problems associated with health-care system in Indonesia. For example, 29.6% of all births occur in homes and assisted by midwives, and are not fully equipped for a wide range of probable complications(8). Births that occur outside hospitals will eventually be referred to nearby hospitals, but many rural areas in Indonesia lack healthcare facilities that are easy to reach during emergency cases.

Moreover, unlike in big cities of Indonesia, these facilities are not properly distributed, thus each facility can hold the burden of a very large area. This causes many of these healthcare facilities to be overcrowded with patients and unable to tend to all patientsâ&#x20AC;&#x2122; needs in time. Furthermore, healthcare facilities in rural areas also lack human resources, equipments, and even electricity. These facilities are also harder to access due to further distance and difficulty in transportation(9). As a result of these problems, sometimes hospitals run out of intensive care units (ICUs) or operating rooms (ORs) and cannot treat patients accordingly. In some cases, in crowded hospitals (also happening in big cities as Indonesiaâ&#x20AC;&#x2122;s population is very dense in these areas), patients have to wait a long time to be treated inside ORs. On top of that, integration of information is also problematic, as there are lots of overlapping and duplication of datas collected(10). The periodic collection of datas also makes most health-care

personnels unaware of incidents happening in neighboring hospitals. In conclusion, Indonesia’s problems regarding the country’s healthcare system includes overcrowded hospitals, lack of resources, inaccessible facilities and lack of integrated information. These problems further impacts in the increase of maternal mortality.

Recommendation From the numerous problems stated above, we would like to propose a solution to improve the efficiency of healthcare facilities. Technological advancements can elevate referring problems by combining and analysing datas from neighboring hospitals. Based on Indonesia’s Ministry of Health Regulations No. 82 Year 2013 regarding Information System in Hospitals (SIM)(11), each hospital have implemented an integrated computer-based information system to record real time datas. However, SIMs among hospitals is not integrated, since every hospital has their own system. Therefore, we propose the creation of HIP, which stands for Healthcare Integration Programme. HIP will fill the gap between systems from different hospitals, and make interhospital cross referencing possible. The program will collect datas from SIMs in different hospitals and analyse each data real time. Hospitals that need to be refer patients to a different hospital will ask for a recommendation, and HIP will calculate the distance and travel time between healthcare facilities, available operation rooms and hospital traffic, and finally come up with choices of hospitals that are most likely available to treat the patients.

●

Improving competency of healthcare personnel especially in primary health care facilities

The Problem Aside from pregnant mothers’ awareness and compliance, medical workers in local healthcare services must be able to provide adequate management for possible obstacle regarding maternal and neonatal health. Medical workers’ competency is one of the key factor to the success of case handling. Therefore, Indonesia’s Ministry of Research, Technology and Higher Educations (KEMENRISTEKDIKTI) along with Ministry of Health cooperates with other entities, such as The Indonesian Medical Council (Konsil Kedokteran Indonesia) and the Indonesian Health Personnel Assembly (Majelis Tenaga Kesehatan Indonesia), sets out the standard competency for medical workers’ license, including physicians, dentists, midwifes and nurses(12-13). However, there is not enough periodic follow-up for licensed workers. Since health-care personnel does not encounter all types of cases in their area, after a period of time, knowledge or skills unpracticed will fade(14). Moreover, integration of health information system and reports is inadequate. This results in a decentralized information system which made monitoring and enforcement

more difficult(13). Therefore, regular competency assessment of medical workers is required to maintain competent licensed healthcare providers.

Recommendations Focusing on maternal health, we propose a simple method to appraise licensed general practitioners and midwives’ proficiency by annually performing an online-based evaluation test, called Evaluation and Training (E&T). A qualified certificated team must be selected by concerned authority to design a multiple-choice-questions (MCQ) by computer based test according to the specific department. The results from this examination will be used as a standard criterion to determine which local healthcare provider needs evaluation. Medical personnel that does not meet the standard of qualification will be marked. This indicate that healthcare providers in the specific area needs further training.

Materials and curriculum will be arranged beforehand by incorporated teams and agreed upon. Qualified physicians and specialists, especially from the obstetrics and gynecology department will be sent to areas with most marks. Each team in charge of the specified area is appointed as coaches and must train the local medical workers. This will provide periodic improvement and maintenance for medical workers’ competency.

Previously marked medical workers, along with those who met the standard qualification will again be tested in the following year. This method can help the government and implicated organizations observe the local medical workers’ progress annually. Furthermore, ‘incompetent’ personnel will annually be trained and monitored, and may hopefully improve their skills to further ameliorate maternal health in their areas.

Conclusion Joint effort by Healthcare system, healthcare personnel and pregnant individuals is needed to improve maternal mortality in Indonesia. We propose some recommendations to meliorate each role. Healthcare system interhospital reference can be achieved by HIP (Healthcare Integration Programme) -- a data analyser that can provide options for available referral hospitals. Secondly, healthcare personnel needs annual evaluations, and those who does not meet the standard qualification will be given trainings by certified personnel. This method can provide generalization for standard competence among nationwide healthcare personnel. Finally, pregnant individuals also need to be exceptionally aware of their own

condition during pregnancy. Therefore, we provide a simple checklist to help raise mothersâ&#x20AC;&#x2122; awareness of possible signs that may lead to maternal and neonatal mortality.

Bibliography 1. Maternal mortality [Internet]. World Health Organization. 2016 [cited 31 October 2017].

Available from: http://www.who.int/mediacentre/factsheets/fs348/en/ 2. Kementrian Kesehatan Republik Indonesia. Indonesia Health Statistics 2016. 2017. Jakarta: Kementrian Kesehatan Indonesia. P102.

3. Indonesia Overview [Internet]. The World Bank in Indonesia. 2017 [cited 31 October 2017].

Available from: http://www.worldbank.org/en/country/indonesia/overview

4. Pusat Data dan Informasi Kementrian Kesehatan RI. Info datin - Motherâ&#x20AC;&#x2122;s day [Internet]. 2014 [cited 31 October 2017]. Available from: http://www.depkes.go.id/resources/download/pusdatin/infodatin/infodatin-ibu.pdf 5. Bakti Husada; Ikatan Dokter Indonesia. Panduan Praktik Klinis Bagi Dokter di Fasilitas Pelayanan Kesehatan Primer. 2014. P605-613.

6. Ministry of Health, Republic of Indonesia. Ministry of Health Republic of Indonesia Regulations No. 18 year 2017 Regarding the Execution of Competency Examination for Medical Personnel (Peraturan Menteri Kesehatan Republik Indonesia No. 18 tahun 2017 tentang Penyelenggaraan Uji Kompetensi Jabatan Fungsional Kesehatan).

7. General Medical Council. Skills fade: a review of the evidence that clinical and professional skills fade during time out of practice, and how skills fade may be measured or remediated: a literature review. 2014.

8. Badan Penelitian dan Pengembangan Kesehatan Kementrian Kesehatan RI. Riset Kesehatan Dasar 2013. 2013. Jakarta: Bakti Husada. P177.

9. Joint Committee on Reducing Maternal and Neonatal Mortality in Indonesia; Development, Security, and Cooperation; Policy and Global Affairs; National Research Council; Indonesian Academy of Sciences. Reducing Maternal and Neonatal Mortality in Indonesia: Saving Lives, Saving the Future. Washington (DC): National Academies Press (US); 2013.

10. Mahendradhata Y, Trisnantoro L, Listyadewi S, Soewondo P, Marthias T, Hrimurti P, and friends. The Republic of Indonesia Health System Review. Health Systems in Transition. 2017; 7(1).

11. Peraturan Menteri Kesehatan Republik Indonesia Nomor 82 Tahun 2013 Tentang Sistem Informasi Manajemen Rumah Sakit.

12. Indonesia Health Profile 2013. (2014). Jakarta: Ministry of Health Republic Indonesia. P.260262.

13. Mikrajab MA, Rachmawati T. Policy Analysis of Integrated Antenatal Care implementation at Public Health Centers in Blitar City. Buletin Penelitian Sistem Kesehatan. 2016; 19(1): 41-53.

14. Ratan Das, S. Eclapmsia: The Major Cause of Maternal Mortality in Eastern India. PubMed Central (PMC). 2017; 25(2): 111-116.

Free Sex Amongst Teenager in Indonesia: A Threat on the Nation Maternal and Neonatal Health Muhamad Faza Soelaeman1, Brenda Christie1, Imam Rahadian Soleman1, Anthonius Yongko1 1

Faculty of Medicine, Universitas Indonesia

Video Access: https://drive.google.com/open?id=0B6437cwSIiU3S3p5eEhjTXpESE0 BACKGROUND Maternal and neonatal health is one of the major health problem faced by Indonesia. According to the Indonesia Demography and Health Survey, the number of maternal health in the nation are still pretty high. In 2012, it has caused around 359 deaths out of 100.000 birth, which is far from the Millenial Development Goals (MDGs) target by 2015 which is 102 deaths. The number of neonatal death are also quiet high with 14 deaths of of 1,000 births. Among those deaths, the number of mortality is ranked 1st from mothers with the age of below 20 as seen in figure 1. From the data, it can be implied that the highest number of mortality among neonatus are from teenage mothers. This is an interesting fact as the survey also found that most teenager stated that the ideal age for marriage starts from after 20 years old. Other than neonatal mortality, teenage pregnancy could also lead into abortion. In fact, 8% of abortion cases come from women below 20 years of age and 33% of cases come from unmarried women. Therefore, there are several risk factors that could lead to such problem, and one of the main and upstream reason is free sex.1,2

Figure 1. Number of deaths classified by the age of the mother

Figure 2. Abortian data in Indonesia

Free sex, which has no official meaning could be implied as casual sex with different sex partners and or pre-martial sex, is currently becoming more common in the society, including the teenager. The Indonesian Demography and Health Survey (SDKI) found that 4.5% and 14.6% of teenager between the age of 15-19 and 20-24 years old respectively has done pre-marriage sex in 2012, growing from 3.7% and 10.5% in 2007. This is due to several reason such as curiosity (57.5% male). According to the WHO, teenager is a population within the age of 10 to 19 years old which is added to 24 years old if referring to the Indonesia National Family Planning Coordinating Board (BKKPN). Teenage year is the periode of considerable growth and development physically, intellectually, and psychologically.

However, due to high level of sexual hormones, teenagers tend to have high curiosity level, eiger to seek adventure, and has the courage to take risks without proper consideration. These group also tend to follow their friends. If decision is taken without further deliberation, teenager would fall into high risk behavior and could have to bear the consequences including short and long term which include problem regarding physical and psychosocial health. Free sex could lead to unwanted pregnancy, creating stress thus increasing the risk of neonatal mortality and abortion.2-5 Free sex could lead people to sexually transmitted disease (STD), such as syphillis, gonorrhae, and HIV. According to the Minsitry of Health, more than 35% of people affected with AIDS are from the age of 15-29 years old. This means that the act of free sex has taken many years of productivity in many people. As much as 28.5% of the patients comes from the age of 30-39 years old. This means that they could get infected from when they were a teenager as HIV virus could only create AIDS after a few years. These people could make their decendant be infected as well thus creating a neonatal mortality

as it has created more than 1% of neonatal death in Indonesia. Other STD could also be transmitted to neonatus, for example Syphillis. If a pregnant woman has Syphillis, it could lead to miscarriage and stillbirth which increase the risk of maternal and neonatal mortality.3,5 Seeing the danger caused by free sex, the government should have taken actions to prevent it creating problem. In the national consititution, there are no rules available on preventing free sex. The only rule regarding it is in KUHP Pasal 284 ayat (1) stating that a person would broke the rule if he/she had sex when they have a wife/husband or when their partner has a wife/partner. It should prevent the danger of free sex on adults, but it could not affect much on teenager. On the other hand, the government has programs regarding this problem for teenager, such as the Adolescent Health Care Program (PKPR) and Planned Generation (GenRe). However, those problems mainly focus on primary health care centers which could not reach as much as teenager as in other centers, such as the primary and secondary school. The education within the program are more likely to be a hit-and-run system done by officials only, thus it would not be sustainable enough.1

SOLUTION Based on the problems facing Indonesia which is caused by the implementation of free sex in teenager, we

proposed

some

solutions

towards

the

issue,

which

include:

1. Creating the STOP Program (Standardized Teaching on Preventing-Free-Sex Program) which is a peer-to-peer based teaching program focusing on educating teenager on reproductive health with a curricullum that could make them able to teach their own friends, family, and relatives. It is created to make an hollistic approach on making teenager get educated about reproductive health which in hope could reduce maternal and neonatal death on those group of age. This program could be done by any medical student in Indonesia or even internationnally and individually or organizationally (for example by the Asian Medical Student Association (AMSA), Central for Indonesian Medical Students Activities (CIMSA), Ikatan Senat Mahasiswa Kedokteran Indonesia (ISMKI)). Hopefully, this program could be implemented in education institution, especially in Junior High School (SMP) and High School (SMA), starting from the School Health Unit (UKS) or into the curricullum itself.

2. Strengthening and promoting available programs for reproductive health education and free sex prevention such as: (1) PKPR, (2) GenRe, (3) Civic, Religion, and Social Education in Primary and Secondary School. As it has been explained before, these program actually has great potential on preventing free sex. Therefore, we as a society should strengthen and further promotes those programs so the effort that the government has created would not goes to waste.

3. Collaborating with national government organization such as the Ministry of Health, the Ministry of Child and Women Protection, and the Ministry of Education and Culture, international organization such as the World Health Organization (WHO), the Joint United Nation Programme on HIV/AIDS (UNAIDS), and the United Nationâ&#x20AC;&#x2122;s Children Fund (UNICEF), and non-govermental organizations (NGO) such as Independent Teenager Alliance, Hope for Teenage Mother (HTM), and etcera with the focus of: (1) education in reproductive health, (2) prevention of free sex in teenager, (3) education for maternal and neonatal health for pregnant teenager or teenage mom, and (4) creating a support group for teenager with reproductive, maternal and neonatal problem.

References: 1. Kementrian Kesehatan RI. Infodatin: Situasi Kesehatan reproduksi remaja. 2016 2. Kementrian Kesehatan RI. Infodatin: Situasi Kesehatan ibu. 2016 3. Kementrian Kesehatan RI. Infodatin: Situasi dan analisis HIV AIDS. 2016 4. Centers for Disease Control and Prevention. Sexually transmitted disease (internet). Atlanta: U.S Department of Health & Human Services; 2016. Available from: https://www.cdc.gov/std/default.htm 5. WHO Statistical Profile. Indonesia. 2015

IMSTC 2018

Indonesia Medical Students' Training and Competition 2018 AMSA Indonesia Bundle of Acads AMSA-UI 2017/2018

IMSTC 2018

Scientific Paper

Bundle of Acads AMSA-UI 2017/2018

Indonesian Medical Students’ Training and Competition (IMSTC) 2018 Early Complementary Feeding as A Risk Factor of Childhood Infections in Indonesia: Milk Bank as Suggested Solution Adrianus Jonathan Sugiharta, Micheylla Kusumaning Dewi, Samuel Pratama Abstract “Weaning” or administration of “Makanan pendamping air susu ibu (MP-ASI)” is a process during which an infant’s diet changes from exclusive breastfeeding to other foods and fluids. It is supposed to be started at 6 months of age, as the baby becomes physiologically mature. Even though early complementary feeding practice has been included in one of the nation’s health program, the compliance of proper feeding in Indonesia is still low. Based on Riskesdas (2013), the prevalence of early weaning in Indonesia reached 69.8%. Early weaning practices in infants has been linked to increased susceptibility to infections. Therefore, this review aims to evaluate its practices, current governmental effort, and try to make solution.

Several databases and search engines (i.e. Google, Pubmed, Google Scholar, and Clinical Key) are used in searching suitable information source. Our search terms include “weaning”, “early weaning”, “early weaning in infant”, “pediatric infection”, and “reasons for early weaning Indonesia”. After matching up with theme, 26 sources are selected and reviewed.

A study found that early weaning practice increases risk to get diarrhea about 7.8 folds.

An explanation is the vulnerable digestive tract toward pathogens and MP-ASI also decreases breastmilk (nutrient and immunity source) consumption. There are many reasons why people still do early weaning practices. One of those reasons is problems in doing the exclusive breastfeeding. The only program currently implemented by Indonesian Health Ministry to control the early weaning among infants is called Keluarga Sadar Gizi (KADARZI).

In conclusion, efforts to eradicate early weaning are proved to be ineffective. Therefore, a solution is proposed to increase and ease the practice of exclusive breastfeeding by creating a system of distribution for ASI, using Posyandu as the center (“Bank ASI” program), hoping this will decrease the practice of early weaning. Ethical and economical aspects have been considered.

Indonesian Medical Students’ Training and Competition (IMSTC) 2018 Early Complementary Feeding as A Risk Factor of Childhood Infections in Indonesia: Milk Bank as Suggested Solution I.

Introduction “Weaning” or administration of “Makanan pendamping air susu ibu (MP-ASI)” is a

process during which an infant’s diet changes from exclusive breastfeeding to other foods and fluids. It aims to fulfill the extra micronutrients and macronutrients required in infants that cannot be supplied by breast milk alone. The American Academy of Pediatrics recommend exclusive breastfeeding for 6 months and continuation to breastfeed for 1 year or even longer.1 However, only 14% of mother complied and most of them introduce complementary solid foods at 3-4 months.2 The first principle of weaning is to begin at 6 months of age, as the gastrointestinal, renal, and nervous system would already be physiologically mature.2 In addition, exclusive breastfeeding prevents comorbidities such as diarrhea, otitis media, urinary tract infection, septicemia, infant botulism, and necrotizing enterocolitis and maximize optimal growth and cognitive development in infants.3, 4 Next, it is recommended to introduce 1 food at a time. It should be rich in zinc, iron, and is energy-dense and fluids other than breast milk, formula, or water are not recommended.1 Even though early complementary feeding practice has been included in one of the nation’s health program, the compliance of proper feeding in Indonesia is still low. Based on Riskesdas (2013), the prevalence of early weaning in Indonesia reached 69.8%.5 In rural regions of Indonesia, 64% of mothers gave solid food within 4 months of age. 6 This is mainly due to the lack of knowledge regarding the timing, regulations, and harmful effect of early complementary feeding (e.g. crying children means hungry, leading to assumption that ASI is not enough).7-15 Due to these problems, this review aims to evaluate how early weaning practices in Indonesia can increase the susceptibility of pediatric infections and make a proposed solution out of it.

II.

Methods This literature review is made to become the informational basis regarding early

weaning practice in Indonesia and its relation toward pediatric infection. The result is used to generate an innovative solution toward this problem. Several databases and search engines (i.e.

Google, Pubmed, Google Scholar, and Clinical Key) are used in searching suitable information source. The sources come from scientific journals, thesis, and trustworthy internet webpages.

Our search terms include “weaning”, “early weaning”, “early weaning in infant”, “pediatric infection”, and “reasons for early weaning Indonesia”. The sources are limited not later than 2008. After matching them with the theme and purpose of the paper, 26 sources are selected and reviewed.

III.

Results and Discussion

Consequences of Early Weaning Practices Early weaning practices in infants has been linked to increased susceptibility to infections. Consequently, infectious diseases can worsen nutritional status, making the child enter this vicious cycle of repeated infections and severe malnutrition.16 Early weaning is found to be associated with increased risks of otitis media, diarrhea, lower respiratory tract infection, eye infection, and malaria.17,18 A study done in North Sumatera reveals that infants having early complementary feeding who had infection are 91.2% compared to those who have completed exclusive breastfeeding 28.6%.19 Moreover, 72.9% of infants having early complementary feeding experienced acute respiratory infections.19 While the risk of having diarrhea among infants given early complementary feeding in Indonesia is 7.8 higher compared to group of infants having completed exclusive breastfeeding.20 Causes of Early Weaning Practices Other than the lack of knowledge regarding proper complementary feeding, new mothers are proven to be more influenced by family and neighbors to perform early weaning, due to lack of experience in handling a child.7,11,13,14 Working mothers would have less time to give breast milk and doing check up to primary healthcare center (Posyandu), leading to early weaning practice.11-13 Bad quality services from the health care giver is also one of the reasons (e.g. giving inadequate information or even recommending early formula milk consumption).

10,11,15

Furthermore, some families give early complementary feeding which runs through generations. In some cases, there are traditions and beliefs in few tribes in Indonesia which influence people to give certain substances way early.7-9,11,14,15 From the economic perspective, family with higher income has the ability to buy and consume formula milks and MPASI products.8,12,15 This fact is also related with increasing advertisements done by the companies that manufacture MPASI products.10,15 No support from family to wean at correct time is also

one main reason.7,11,13,14 Lastly, problems with giving breast milk, such as incorrect position which leads to nipple laceration and inability to produce milk make mothers “traumatized” to breastfeed and choose to give complementary food instead.7, 9, 15, 21 Government Action Indonesian government seems to have little awareness regarding the infant feeding practices, especially early weaning. Until now, there is no national regulation or policy on infant and child feeding practices implemented yet planned. There is only a ministerial decree which specifically provides information and regulation regarding the marketing of breastmilk substitutes (KEPMENKES No. 27/MENKES/SK/IV/1997). However, there is not any clear and assertive punishment for those who violates. There is also a program which focuses on infant and child nutrition and health. However, this program is not supervised by the government itself, but by NGOs such as Gerakan Kesehatan Ibu dan Anak (GKIA).22 The only program currently implemented by Indonesian Ministry of Health in order to achieve lower malnutrition rate among infants is called Keluarga Sadar Gizi (KADARZI). Through this program, every family in Indonesia is encouraged to practice exclusive breastfeeding up to the age of 6 months and then continue with MP-ASI (Makanan Pendamping ASI) up to the age of 2 years. Even so, there is no reliable data regarding the progression and effectivity of this program.23, 24 IV.

Conclusion and Solution Complementary feeding period should start at the age of 6 months as the organ systems

of the infant have physiologically mature and ready to handle more solid food. Careful administration of the right complementary food and fluids should also be considered.

Disobedience to these principles may weakens the child’s immunity, making them more susceptible to infections. There are some reasons why the prevalence of early weaning is still high in Indonesia, which are the lack of knowledge regarding MP-ASI, certain cultural beliefs, lack of time or problem regarding exclusive breastfeeding, and the lack of support from family.

Due to ineffective efforts to eradicate the lack of knowledge regarding MP-ASI, through educational programs, we would like to propose a solution to increase compliance of exclusive breastfeeding by creating a system of distribution for ASI, using Posyandu as the center (we called it as “Bank ASI” program). There are a lot of mothers who overproduce ASI, and the fact that ASI can be kept for up to 12 months using freezer, make it possible to be stored and distributed.25 We hope that mothers would give distributed-ASI instead of MPASI to their “crying and hungry” children.

For the ethical issue, it is stated in the Analisis Fatwa MUI Nomor 28 Tahun 2013 Tentang Seputar Donor Air Susu Ibu that it is not forbidden to receive ASI from other person.

However, it is mentioned that there is a law that forbids the receiver of the ASI to marry the children of the ASI giver.26 It is why the ASI donor will be quality-checked and sorted according to religion (some people believes they should receive from the same religion) and sex (matching the gender for donor’s children and ASI receiver). To increase public participation, this program can be integrated with current government program (KADARZI) and also give compensation for ASI donors. Detailed mechanism and standard of operation are yet to be discussed.

V.

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18. Krawczyk samA, Lewis MG, Venkatesh BT, Nair SN. Effect of Exclusive Breastfeeding on Rotavirus Infection among Children. The Indian Journal of Pediatrics. 2016 Mar;83(3):220–5.

19. Desi Wulandari, Ganis Indriati, Arneliwati. Hubungan pemberian makanan pendamping ASI (MP-ASI) dini terhadap kejadian ISPA pada bayi usia 0-6 bulan. Universitas Sam Ratulangi. 2016; 20. Maharani O. Pemberian Makanan Pendamping ASI Dini Berhubungan dengan Kejadian Diare pada Bayi umur 0 â&#x20AC;&#x201C; 12 bulan di Kecamatan Dampal Utara, Tolitoli, Sulawesi Tengah. Jurnal Ners dan Kebidanan Indonesia. 2016 Aug 3;4(2):84.

21. Pediatri D. HUBUNGAN PEMBERIAN MAKANAN PENDAMPING ASI DINI DENGAN INSIDEN DIARE PADA BAYI USIA 1 - 4 BULAN [Internet]. 2008 [cited 2017 Dec 28]. Available from: http://eprints.ums.ac.id/4020/1/J500040023.pdf 22. Indonesian Breastfeeding Mothers Association, Geneva Infant Feeding Association.

Report on the situation of infant and young child feeding in Indonesia. International Baby Food Action Network (IBFAN); 2014 23. Departemen Kesehatan RI. Pedoman umum pemberian makanan pendamping air susu ibu (MP-ASI) lokal tahun 2006. Jakarta: Depkes RI; 2006 24. Departemen Kesehatan RI. Buku saku kader pendamping menuju KADARZI. Jakarta: Depkes RI; 2006 25. Center of Disease Control. Proper Handling and Storage of Human Milk | Breastfeeding | CDC [Internet]. Breastfeeding. 2017 [cited 2017 Dec 28]. Available from: https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm 26. Ulum AN. ISTIRDLAâ&#x20AC;&#x2122; DALAM PANDANGAN HUKUM ISLAM (Analisis Fatwa MUI Nomor 28 Tahum 2013 Tentang Seputar Donor Air Susu Ibu) [Internet]. Raden Intan Repository. 2017 [cited 2017 Dec 28]. Available from: http://repository.radenintan.ac.id/705/

Indonesian Medical Students’ Training and Competition 2018

The Potential Application of Malaria Vaccine RTS,S/AS01 for Indonesian Children Brian Mendel, Angga Wiratama Lokeswara In 2016, WHO estimated that there are 216 million people infected with Malaria in 91 countries. In 2015, it is found that 70.6% of malaria mortality were in children under 5 years of age. In Indonesia, the national incidence of malaria has increased from 1.9 to 2.9% in 5 years and the prevalence of malaria in 2013 reached 6.0%. Despite the high burden of malaria in Indonesia, the prevention of malaria mainly focuses on vector control, surveillance, and at best, chemoprophylaxis. On the other hand, chemoprophylaxis agent was not being very effective prior to the rising cases of P. falciparum-resistance in Asian countries. One of the solutions to counter this problem is the malaria vaccine RTS,S/AS01 which currently undergo a phase III clinical trial. Therefore, this review has 3 main objectives: (1) Exploring the latest known clinical performance of RTS,S/AS01 vaccine; (2) Comparing RTS,S/AS01 vaccines against the current chemoprophylactic drugs; (3) Evaluating the integration of RTS,S/AS01 vaccines into the Indonesian government’s malaria eradication scheme. We searched literatures for Pubmed, Google Scholar, and ScienceDirect and reviewed 28 literatures in total and found the clinical performance of RTS,S/AS01 vaccine efficacy against clinical malaria following three primary doses are 45.1%, 35.2%, and 28.3% during 20, 32, and 48 months of follow-up, respectively. In comparing RTS,S/AS01 vaccines against the current chemoprophylactic drugs, we have come to conclusion that although the most recent trial of RTS,S/AS01 vaccine shows mediocre efficacy, it may still be the most potential prophylactic tool in Indonesia, considering that the trial was only conducted in African countries. By overcoming the current hurdles in the development of RTS,S/AS01 vaccine, we believe that with more studies, its implementation has the potential to help the Indonesian government’s efforts in eradicating malaria, and eventually, help the global community to save millions of children worldwide.

Keywords:

“RTS,S/AS01”,

“chemoprphylactic drugs”

“malaria

vaccine”,

“P.falciparum”,

“Indonesia”,

Indonesian Medical Studentsâ&#x20AC;&#x2122; Training & Competition (IMSTC) 2018

The Potential Application of Malaria Vaccine RTS,S/AS01 for Indonesian Children Authored by: Brian Mendel Angga Wiratama Lokeswara

The Potential Application of Malaria Vaccine RTS,S/AS01 for Indonesian Children Brian Mendel, Angga Wiratama Lokeswara I. Introduction WHO estimated that there are 216 million people infected with Malaria in 91 countries around the world in 2016. In 2015, the estimated mortality of malaria reached 446,000, 70.6% of which were in children under 5 years of age.1 In the Sustainable Development Goals (SDGs), it is one of the global commitments to eradicate the epidemics of malaria by 2030, as stated in the third objective, “Good Health and Well-Being”, specifically in the target number 3.3.2 In Indonesia, according to the Riset Kesehatan Dasar (Riskesdas) 2013, the national incidence of malaria has increased from 1.9 to 2.9% in 5 years and the prevalence of malaria in 2013 reached 6.0%, especially in the 5 regions with the highest incidence and prevalence, namely Papua, Nusa Tenggara Timur, Papua Barat, Sulawesi Tengah and Maluku.3 Despite the towering problem, at the present time, the prevention of this pediatric infectious disease mainly focuses on vector control, surveillance and monitoring, and at best, chemoprophylaxis. In the WHO Global Technical Strategy for Malaria 2016 – 2030, research in malaria vaccine is included only as a supporting element, although there is a global call for the malaria vaccine by 2030.4 In Indonesia, the approach to Malaria is comprehensively regulated in the Health Minister’s Decree No. 293/MENKES/SK/IV/2009 on Elimination of Malaria states that the main strategies of prevention are the use of insecticidal nets and indoor spraying.5 However, these strategies are merely focusing on the elimination of vector, hence are not completely protecting the individuals outdoor. Another approach is to provide chemoprophylaxis such as artemisinin and chloroquine. Unfortunately, the resistance to the antimalaria drug is now rising, especially in Asian countries, including Indonesia.6 In light of the immense hurdles, there have been efforts to develop an effective vaccine for malaria. Some of the candidates include RTS,S/AS01, which is in Phase III trial, ChAd63/MVA ME-TRAP and PfSPZ, which are both in Phase 2b trials.7 Amongst these vaccines, RTS,S/AS01 is the most studied and well-established, and has been put to trial in

humans in Ghana, Kenya and Malawi. With the endemicity of malaria in Indonesia, the currently rather ineffective preventive measures, and the rising resistance to anti-malaria drugs, the vaccine becomes the highly potential tools to curtail the burden of the disease in Indonesia.

Therefore this review has 3 main objectives: (1) Reviewing the latest known clinical performance of RTS,S/AS01 vaccine; (2) Comparing RTS,S/AS01 vaccines against the current chemoprophylactic drugs; (3) Evaluating the integration of RTS,S/AS01 vaccines into the Indonesian government’s malaria eradication scheme.

II. Methods We performed the study by searching through PubMed, Google Scholar and ScienceDirect, restricting studies published in English and Bahasa Indonesia, in the years of no later than 2007, with focus on studies published after 2012, except few older references frequently cited.

Our search terms included “malaria”, “falciparum”, “vaccine”, “RTS,S/AS01”, “artemisinin” and “chloroquine”, cross-referenced with terms such as “prevention”, “prophylaxis”, and “Indonesia”.

Figure 1 Schematic diagram of the methods used in this review.

In total, we used 28 literatures on this review, 8 of which to review the clinical profile of RTS,S/AS01 vaccine, 5 of which to review chloroquine as a prophylactic drug, 9 of which to review artemisinin as a prophylactic drug and 6 others to assess the potential integration of the vaccine into Indonesian governmentâ&#x20AC;&#x2122;s program and to support our review. Our method can be explained in Figure 1 above.

III. Results and Discussions 1) Â Clinical Profile of Malaria Vaccine RTS,S/AS01 RTS,S/AS01, also known as Mosquirix is a malaria vaccine candidate which consist of hepatitis B surface antigen virus-like particles, integrating a portion of the Plasmodium falciparum-derived circumsporozoite protein and a liposome-based adjuvant.8 RTS,S (adjuvant with AS01) targets the circumsporozoite protein (CSP) of Plasmodium falciparum; this vaccine is a virus-like particle expressed in Saccharomyces cerevisiae that comprises of recombinant hepatitis B surface (S) antigen and a fusion protein containing the repeat (R) and C-terminal (T) regions of the CSP fused to the recombinant S antigen.9 RTS,S/AS01 is liposomal based and possess immunostimulants monophosphoryl lipid A and QS21 (a triterpene glycoside purified from the bark of Quillaja saponaria).10 RTS,S targets the Plasmodium falciparum life cycle in the preerythocytic stage.9 The structure can be seen in Figure 2 below.

Figure 2 Schematic representation of the circumsporozoite protein(CSP), a predominant surface antigen on sporozoites (above) and the malaria vaccine RTS,S (below). This vaccine is a virus-like particle expressed in Saccharomyces cerevisiae that comprises of recombinant hepatitis B surface (S) antigen and a fusion protein containing the repeat (R) and C-terminal (T) regions of the CSP fused to the recombinant S antigen.9,11

There are 8,922 children and 6,537 young infants included in a large phase III trial of RTS,S/AS01 at 11 sites in seven-sub Saharan African countries in the modified to intentionto-treat analyses. Vaccine efficacy (VE) against clinical malaria in infants between 6 to 12 weeks, declined from 27.0% to 20.3% to 18.3% during 20, 32, and 48 months of follow-up respectively (95% Confidence Interval [CI] 21.1 to 32.5). Evidence for protection in young children 5-17 months was more encouraging. The VE against clinical malaria following three primary doses are 45.1%, 35.2%, and 28.3% during 20, 32, and 48 months of follow-up, respectively. An additional booster dose at 18 months elevated the VE from 28.3% to 36.3%.

Protection wane over time, with the highest efficacy noted soon after vaccination. In the children aged 5-17 months, there were 21 cases of meningitis in the 5,948 RTS,S/AS01 recipients and one in the 2,974 controls. The safety and efficacy of this malaria vaccine has also been demonstrated in small numbers of North American adults12 and African adults.13 Each vaccine dose is expected to cost around US$5.14 A three-dose regimen with a booster will cost about US$20, not including the cost of delivery.15 To recommend the utilization of the vaccine in the older age group (5 to 17 months) in malariaendemic countries, the committees will require more information on the safety, feasibility, and effectiveness of RTS,S/AS01. The majority of malaria cases occurred in children under 5 years, and children who survived to school age had significant protective immunity. It is essential to develop a vaccine that would protect children as early as possible. However RTS,S/AS01 vaccination provides minimal immunization in infants and the better efficacy in older children wanes rapidly.6 2) Â Comparison between Malaria Vaccine RTS,S/ASO1 and Other Chemoprophylactic Drugs In the treatment of Plasmodium falciparum malaria, a greater risk of adverse effect to antimalarial drugs is inevitable. The toxicity of these antimalarial agents should be considered even though alternative agents may be utilized in therapeutic regimens since chloroquine resistance has become widespread. Plasmodium falciparum, which is responsible for causing severe form of the disease, is also clever at developing resistance to drug, thus decreasing their efficacy in treatment over a period of time. Moreover, many research that are being conducted to administer them into the drug registration tends to exclude two important groups who are especially vulnerable to malaria: very young children and pregnant women.6

2.1 Chloroquine Chloroquine is effective against drug-sensitive P.falciparum and could be used as prevention or treatment. Mild side effects include nausea and headache. Africans in comparison to African-Canadians could experience generalized pruritus, and is not indicative of drug allergies. Some genetic markers, notably hemoglobin genotype and G6PD, have been found to be associated with chloroquine-induced pruritus.

Chloroquine is contraindicated in individuals with a history of epilepsy or generalized psoriasis.6 2.2 Artemisinin and its derivatives Artemether-lumenfantrine is a fixed-dosed oral antimalarial drug which integrate the fast action onset of artemether (an Artemisinin derivative) in terms of parasite clearance with the high cure rate of lumefantrine in the treatment of acute uncomplicated P.falciparum malaria. The most commonly adverse effect include abdominal pain, anorexia, nausea, vomiting, diarrhoea, and CNS involvement. It could as well be an alternative treatment options for travellers to endemic countries.6 In order to compare the use of vaccine RTS,S/AS01 with other p.falciparum prophylactic agents, namely, chloroquine and artemisinin, we have summarised a few important aspects regarding their characteristics and application in Table 1. Malaria vaccine RTS,S/AS01 targets the P.falciparum life cycle in preerythocytic stage, while chloroquine and artemisinin targets the asexual intraerythocytic forms by utilizing generation of free radicals.16, 21,22 There has been emerging cases of P.falciparum resistance of chloroquine and artemisinin. Prior to the resistance, chloroquine was only effective on Plasmodium falciparum chloroquine-sensitive.

Artemisinin was recommended as standard treatment worldwide and its usage was combined with other drugs, for example artemether-lumenfantrine,6 although P.falciparum resistance has been reported in several Asian countries, such as western Cambodia, Thailand, Vietnam, Eastern Myanmar, and Southern Laos.23-26 Due to these downfall, Malaria vaccine RTS,S/AS01 could be a promising solution in countering P.falciparum resistances. However, RTS,S/AS01 possess low to moderate efficacy and tend to wane rapidly in older children.12,13 Both chloroquine and artemisinin were utilized by combining them with other anti-malarial drugs, while RTS,S/AS01 was used as monotherapy and injected in two sites intravenously.12,13,16,27 Safety of malarial drugs in children and pregnant women is one of the

Table 1 Comparison of malaria vaccine RTS,S/AS01 with other p.falciparum prophylactic agents.8,9,12-28 RTS,S/AS01

Active substances

Mechanism of action

towards p.falciparum

Usage

7-chloro-N-[5-

falciparum-derived

(diethylamino)pentan-

Sesquiterpene lactone containing

circumsporozoite

2-yl]quinolin-4-

an unusual peroxide bridge.20

protein.8

amine.16

targets the

Inhibit heme

Not known, accepted theory is

Plasmodium

polymerase activity.

activated through cleavage after

falciparum life cycle

Accumulation of free

reacting with haem and iron (II)

in the preerythocytic

heme thought to be

9

Low to moderate efficacy, but tend to wane rapidly in older children.12,13 Injection in two different sites.

12,13

Unknown.12,13

women

Limitation

and result in generation of free

toxic to p.falciparum.

Safety in children and in pregnant

Artemisinin

Plasmodium

stage.

Effectiveness

Chloroquine

16

Standard treatment worldwide Only effective in

for p.falciparum malaria, even

p.falciparum

though there is resistance

chloroquine-sensitive.17

reported in several Asia countries.23-26

Often in combination with other malarial drug.

No harmful effects on

No harmful effects on the fetus

the fetus when used for

when used for malaria

18

Lack of clinical

Effectiveness declined

evidence regarding

since the

safety in children

documentation of P.

and pregnant

falciparum chloroquin

woman.

Often in combination with other malarial drug.27

16

malaria prophylaxis.

12,13

radicals.21,22

prophylaxis.28

Resistance in several Asia countries.23,24

resistance in 1950.17

US$5, with three Cost

time booster which

10 US cents.19

US$ 2.40.19

cost US$20.14,15

most essential factors in predicting the risk-benefit ratio. Chloroquine and artemisin show no harmful effects on the fetus when used as malaria prophylaxis. In the other hand, RTS,S/AS01 lack of clinical evidence regarding the safety. As an new developed vaccine against clinical malaria, RTS,S cost higher than chloroquine and artemisinin, which both cost 10 US cents and US$2.40, respectively.14,15,19 All of these information has been summarized in Table 1.

All in all, weighing the risks and benefits, with the malaria being endemic in Indonesia, the currently rather ineffective preventive measures, and the rising resistance to anti-malaria drugs, the RTS,S/AS01 vaccine seems to be the most potential prophylactic measure for Indonesia, mainly due to the resistance issue amongst the Asian countries.

3) Potential Integration of RTS,S/AS01 Vaccines into the Indonesian Government’s Malaria Eradication Scheme The long term plan for eradication of malaria in Indonesia was drawn in 2009 and is officially regulated in Health Minister’s Decree No. 293/MENKES/SK/IV/2009 on Elimination of Malaria with the target of eliminating malaria by 2030. In general, the plan is divided into 4 stages: (1) Eradication; (2) Pre-elimination, which is targeted that by 2020, all regions in Indonesia would have entered the pre-elimination stage; (3) Elimination, which is targeted that by 2030, all regions in Indonesia would have entered the elimination stage; (4) Maintenance, at which it is hoped that the WHO certification can be achieved in the end.5 In each of the aforementioned stages, there are 5 main targeted areas of intervention: 5 a. Detection and treatment of infected individuals This includes microscopic confirmation of malaria in all places, standardization of treatment for malaria using Artemisinin Combination Therapy (ACT) and regulating the illegal sale of antimalaria drugs b. Prevention and risk-factor management This includes mass distribution of insecticidal net and indoor spraying in endemic areas, as well as monitoring their efficacy and emerging vector resistance c. Epidemiological surveillance and outbreak management This includes inventorying and mapping of epidemiological area, prompt reporting of malaria cases, and management of outbreak d. Strengthening communication, information and education This includes establishing cooperation with non-governmental organizations and social services, better management of information and more rigorous socialization and education e. Improvement of human resources This includes orientation and training for all the people involved in the malaria management.

All of the programs above show that Indonesia has already had a well-planned long-term program for the eradication of malaria. This will serve as a golden platform for the introduction and integration of RTS,S/AS01 vaccine into the Indonesian governmentâ&#x20AC;&#x2122;s plan in eliminating malaria. The introduction of the vaccine can be integrated in the target (b) as part of the prevention and risk-factor management to improve the outcome of the prevention. This will be an approach targeted at the individuals, as opposed to only the vector, hence making the efforts of prevention more comprehensive and wholesome. The integration into the current system is shown in the Figure 3 below.

Figure 3 The current Indonesian governmentâ&#x20AC;&#x2122;s malaria eradication scheme,5 and the potential integration of RTS,S/AS01 vaccines into the scheme.

4) Â Current Limitations and Future Studies The vaccine efficacy waned rapidly in both infants aged 6 to 12 weeks and young children 5 to 15 months old. Even though RTS,S/AS01 is considered safe, vaccine recipients in the age group of 5 to 17 months experienced meningitis in comparison to children who received the control vaccine. Therefore, further research regarding safety of the vaccine towards pregnant women and children need to be elaborated. In order to recommend the utilization of the vaccine in the older age group (5 to 17 months) in malaria-endemic countries, the committees will require more information on the safety, feasibility, and effectiveness of RTS,S/AS01.8-10 Studies regarding its clinical performance in Asian population will also be much anticipated.

IV. Conclusion Despite the currently high burden of malaria in children in countries like Indonesia, to date, the prevention of Malaria mainly focuses on vector control, surveillance and monitoring, and at best, chemoprophylaxis. The emergence of a promising malaria vaccine RTS,S/AS01 gives new hope towards achieving eradication of malaria by 2030, as targeted by WHO and Indonesian government. This review has set out 3 main objectives: (1) Exploring the latest known clinical performance of RTS,S/AS01 vaccine; (2) Comparing RTS,S/AS01 vaccines against the current chemoprophylactic drugs; (3) Evaluating the integration of RTS,S/AS01 vaccines into the Indonesian governmentâ&#x20AC;&#x2122;s malaria eradication scheme. We have therefore come up with a framework of idea as can be seen in Figure 4 below, where the introduction of RTS,S/AS01 vaccine can be well integrated into the Indonesian system.

Figure 4 Integration of RTS,S/AS01 vaccine into the Indonesian system We searched literatures for Pubmed, Google Scholar, and ScienceDirect and reviewed 28 literatures in total. In exploring the latest known clinical performance of RTS,S/AS01 vaccine, we found that this malaria vaccine targets the circumsporozoite protein of Plasmodium falciparum in the preerythocyctic stage. The vaccine efficacy against clinical malaria following three primary doses are 45.1%, 35.2%, and 28.3% during 20, 32, and 48 months of follow-up, respectively. However, the trial also shows that children with the age of 5-17 months experience 21 cases of meningitis in the 5,948 RTS,S/AS01 recipients and one in the 2,974 controls. Therefore, it is imperative to conduct studies regarding the safety, especially in two susceptible groups, pregnant woman and children.

In comparing RTS,S/AS01 vaccines against the current chemoprophylactic drugs, we have come to conclusion that although the most recent trial of RTS,S/AS01 vaccine shows a lower efficacy in a certain age-group, it may still be the most potential prophylactic tool in Indonesia.

This is because the trial was only conducted in African countries, meanwhile the Asian countries are also fighting the rising resistance against the currently available chemoprophylactic drugs, whereas other second-line drugs also has harmful side effects.

Currently, the Indonesian government has also set out a long term plan for the eradication of malaria, as regulated in Health Ministerâ&#x20AC;&#x2122;s Decree No. 293/MENKES/SK/IV/2009 on Elimination of Malaria. Amongst the areas targeted in the scheme is the prevention and riskfactor management which is at the present time, only focuses on vector control measures such as insecticidal nets and indoor spraying. The introduction of RTS,S/AS01 vaccines will be an apt additional measure which targets the individual protection, so that the preventive measures in the endemic regions of Indonesia will be more holistic.

By overcoming the current hurdles in the development of RTS,S/AS01 vaccine, we believe that with more studies, its implementation has the potential to greatly help the Indonesian governmentâ&#x20AC;&#x2122;s efforts in eradicating malaria, and eventually help the global community to save millions of children worldwide.

V. Bibliography 1.

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10. Mettens P, Dubois PM, Demoitie MA. Improved T cell responses to Plasmodium falciparum circumsporozoite protein in mice and monkeys induced by a novel formulation of RTS,S vaccine antigen. Vaccine 2008; 26: 1072-82 11. Lubanga B, Chemtai A, Kwaro D. The RTS,S/AS Malaria Vaccine Candidate: A Status Review. International Journal of Medicine & Health Research 2016; 2(1):1-9 12. Stoute JA, Slaoui M, Heppner DG, Momin P, Kester KE, et al. (1997) A preliminary evaluation of a recombinant circumsporozoite protein vaccine against Plasmodium falciparum malaria. RTS,S Malaria Vaccine Evaluation Group. N Engl J Med 336: 86– 91.

13. Bojang KA, Milligan PJ, Pinder M, Vigneron L, Alloueche A, et al. (2001) Efficacy of RTS,S/AS02 malaria vaccine against Plasmodium falciparum infection in semi-immune adult men in The Gambia: a randomised trial. Lancet 358: 1927–1934.

14. Gulland A. Malaria vaccine difficult to roll out because four doses are needed, WHO says. BMJ 2015 Oct 26 ;351:h5706 15. World Development Indicators | The World Bank [Internet]. Wdi.worldbank.org. 2017 [cited 29 December 2017]. Available from: http://wdi.worldbank.org/table/2.15 16. Chloroquine - DrugBank [Internet]. Drugbank.ca. 2017 [cited 29 December 2017].

Available from: https://www.drugbank.ca/drugs/DB00608 17. Martin RE, Marchetti RV, Cowan AI, Howitt SM, Broer S, Kirk K. Chloroquine Transport via the Malaria Parasite's Chloroquine Resistance Transporter. Science 2009; 325 (5948): 1680–2.

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24. Dondorp AM, Nosten FO, Yi P, Das D, Phyo AP, Tarning J, et al. Artemisinin Resistance in Plasmodium falciparum Malaria. New England Journal of Medicine 2009; 361 (5): 455–467.

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Preventable Risk Factors and Recommended Protective Factors Associated with Rotavirus Diarrhea among Children Under-Five: A Systematic Review of Large CaseControl Study Jeremy Rafael Tandaju*, Alice Tamara * jrmrafael@gmail.com, +6281311541552

Introduction: Child-death is chronic health problem worldwide. Hourly, 15,000 children under-five die â&#x20AC;&#x201C; 9% are diarrhea-based and mainly rotavirus-caused. Rotavirus diarrhea (RD) kills 453,000, including 10,888 Indonesian children yearly and doubled its prevalence during last two decades. Although various preventions have been taken, its prevalence and mortality rate are still high. Thus, we conduct a systematic review to identify the risk and promoting factors in reducing its prevalence and mortality rate.

Methods: We conduct a systematic review of large case-control studies of children under-five with RD at Pubmed and EBSCOhost (n= 467). Eligible studies (n= 11) involving 10,248 respondents which passed inclusion criteria were assessed with STROBEâ&#x20AC;&#x2122;s criteria for further review.

Results and Discussion: Top-3 risk factor group contributing to U-5 RD were identified: 1) Being outside home is notably enhancing including day-care center attendance (OR= 6.0), travelling (OR= 3.97), and hospitalization (OR= 3.81).

2) Immune system elevates the risk by internal factor, such as low birth weight (OR= 6.00), low maturity (OR= 12.10) and prematurity (OR= 5.20); along with external factors: being wasted (OR= 9.00) and no breastmilk (OR= 2.27).

3) Poor hygiene and sanitation increase the risk factor including contaminated water (OR= 6.92), un-facilitated defecation (OR= 2.7), and toilet-sharing (OR= 1.6). Furthermore, left garbage (OR= 3.2), no soap and towels (OR= 1.6) yet determining.

Additionally, such protective factors as breastmilk feeding was found to show a favorable effect in reducing RD risk by exclusive breastfeeding (OR= 0.44).

Conclusion: Being outside home, immune system, and poor hygiene and sanitation were acknowledged as major risk factors of U-5 RD, supported by other factors founded along review. Exclusive breastfeeding is acknowledged as main protective factor. Hence, these factors are expected to enlighten caregivers and HCW to prevent and reduce mortality rate of diarrhea, especially U5 RD in-order to fulfill SDG 3.2 by 2030.

Indonesian Medical Studentsâ&#x20AC;&#x2122; Training & Competition (IMSTC) 2018 Scientific Paper

Preventable Risk Factors and Recommended Protective Factors Associated with Rotavirus Diarrhea among Children Under-Five: A Systematic Review of Large CaseControl Study

By: Jeremy Rafael Tandaju Alice Tamara

Preventable Risk Factors and Recommended Protective Factors Associated with Rotavirus Diarrhea among Children Under-Five: A Systematic Review of Large CaseControl Study Jeremy Rafael Tandaju*, Alice Tamara *jrmrafael@gmail.com, (+62) 81311541552 INTRODUCTION Child death is a prolonged problem worldwide. World Health Organization (WHO) estimated that 15,000 children under the age of 5 (U-5) die hourly â&#x20AC;&#x201C; 9% of them are caused by diarrhea serving as the second largest factor.1 Diarrhea is caused by various agents, including rotavirus as global leading agent which kills 453,000 U-5 children yearly â&#x20AC;&#x201C; which involves 10,888 Indonesian.2,3 One infectious etiology which is prevalent worldwide is especially rotavirus [Figure 1]. Rotavirus is a highly transmissible virus which causes gastroenteritis, manifested in severe watery diarrhea, accompanied with vomiting, fever, and abdominal pain. 4 Its contribution to diarrhea has expanded from 1999 (22%) to 2013 (56%), which bolded its progressiveness and hazard.5

Figure 1. Rotavirus-caused diarrheal incidence distribution worldwide in 2013.6 Actions have been taken in-order to fight rotavirus. WHO has recommended rotavirus vaccines (RV) as a mandatory vaccination in all country, especially countries with high fatality

rates such as South-Eastern Asia. 2 In addition, Indonesia has implemented RV regiment since 2011 and planning to fully subsidize it in coming years with BPJS – a national insurance program. 3 Despite efforts done to solve this chronic health problem, current prevalence and mortality rate of RD are still very high.

Hence, this systematic review has the main objective to: (1) identify the risk and protective factors contributing to the occurrence of RD, (2) promote healthy lifestyle depending on the obtained risk and protective factors to decrease the prevalence and mortality rate of RD in the future, and (3) enlighten caregivers and health-care workers to reduce mortality caused by diarrhea, to fulfill Sustainable Development Goals (SDG) 3.2 by 2030. 7 MATERIAL AND METHODS a) Study Search Strategy We conduct a systematic review of case-control studies to analyze protective and risk factors associated with RD in U-5 children based on PRISMA Statement.

8,9

We conducted

literature review from Pubmed and EBSCOhost on 29 December 2017 using the keywords “rotavirus OR viral OR virus”, “diarrhea”, “risk factors”, and “infant OR children OR child OR toddler”. b) Inclusion and Exclusion Criteria a. Inclusion Criteria •

Case-control study

•

Study rotavirus associated diarrhea

•

Subject is U-5 children

•

Identify the risk and protective factors of rotavirus associated diarrhea

b. Exclusion Criteria •

Immunocompromised patients

•

Have antibiotic taken before examination

•

Subject aged more than 5-year old

•

Unauthentic article

•

Articles not accessible by all methods

c) Data Extraction After identifying relevant articles to be analyzed, we set the necessary data to be extracted from the studies. The following data was extracted from the studies: -

Author and year of publication

-

Study design

-

Location of study

-

Sample size and ratio

-

Subject mean of age

-

Method of analysis

-

Outcome: picturized by odds ratio for each factor.

d) Study Quality Assessment The studies chosen are assessed through “Strengthening the Reporting of Observational Studies in Epidemiology” / STROBE’s Criteria of case-control study which includes 22 criteria in which 1 point is given to the study when each criteria are fulfilled. The quality assessment of the studies was conducted by two reviewers independently and concluded after consensus of each different rating were reached.

RESULTS a) Research Findings and Study Selection The search was conducted via Pubmed and EBSCOhost. Titles were screened for relevancy and the contents were screened further for inclusion and exclusion criteria. Articles went over criteria were fully assessed for eligibility and study design. Finally, 11 suitable casecontrol articles were reviewed and included in the systematic review. The holistic data on the study selection process can be seen in Figure 2:

Figure 2. Flow chart of search strategy

b) Quality of the Included Studies From the result of this quality assessment, all studies were acknowledged as good quality studies which can be seen in the table below: Table 1. Studies Quality Assessment based on STROBEâ&#x20AC;&#x2122;s Criteria

c) Study Designs and Characteristics Table 2. Included Study Designs and Characteristics

all the RR and OR provided in the previous table have p-value<0.05 RR = relative risk; OR = odds ratio

DISCUSSION a) Analysis of the Study There are various risk and protective factors linked to U-5 RD. Due to feasibility and importance based on the quality of previously assessed studies, we list 3 main risk factors and a protective factor contributing to U-5 RD: Being Outside Home Children who spend more time outside home tend to be more prone to RD. According to Reves RR, Paul A, and Ethelberg S, being in day-care center increase the risk by 2.4, 6.0, and 1.33 folds respectively. In contrast, being cared for 3 or more days at home reduce the risk by 10 folds according to Paul A. In addition, study by Ethelberg S mentioned that being on a travel and hospitalized enhance the risk by 3.97 and 3.81 folds respectively.

These conditions are supported by the fact that rotavirus is passed through contaminated hands, objects, food or water with infected feces – then ingested by mouth.21 Furthermore, not only by feces, it could be shed from the oropharynx of children with respiratory problems, thus makes it more versatile in transmission in public places.22 After rotavirus is discharged, it will become extremely stable and viable in environment for months if not disinfected.21 Lack of Immunity Weak immunity expands the risk of having RD. It is caused by internal and external factors. Internally – low birth weight, low maturity, and prematurity enlarges the risk by 6.0, 12.10, and 5.20 folds respectively according to study held by Widdowson M. This could happen as low weight enhances greater peripheral T-cell turnover which lower immune functional reserve and system.23 In addition, premature and un-mature child tends to have fewer and impaired monocytes, neutrophils, and cytokines which reduce T cell activation thus lower bacteria elimination.24 Externally – Randremanana and Maponga stated that being wasted and no breastmilk increase the risk by 9.00 and 2.27 folds respectively. These occur because wasted children are having a low weight whose effects mentioned above – combined with malnutrition, and fewer

immunoglobulin attained (10-100 folds higher than serum) because of no breastmilk.

Therefore, immune system will be altered and open the way for RD. Poor Hygiene and Sanitation Poor sanitation, which commonly involves water elevate the risk of RD. Studies held

by Nhampossa and Nimri shown that suspected contaminated water enhances the risk by 6.92 and 2.25 folds respectively. In addition, another study by Nhampossa and Sobel shown that unfacilitated defecation increase the risk by 2.7 and 2 folds respectively. Furthermore, Mansour stated that sharing toilet with others increase the risk by 1.6 fold. It is very possible considering that fecal-oral and water passage are rotavirus main transmissions way, thus no sanitation will could transmit rotavirus extremely easy.21 Poor hygiene, such as garbage around house and no soap and towels increase the risk by 3.2 and 1.6, according to study held by Randremanana and Mansour respectively. These are reasonable considering that rotavirus could be viable in environment for months unless it is disinfected or eradicated along with the environment.21 Breast-Milk Feeding Breastmilk has been commonly known to play an important part in supporting the innate immune system for infantsâ&#x20AC;&#x2122; digestive tract. According to studies done by Clemens J, Maponga BA, and Nhampossa, exclusive breastfeeding has a tendency to reduce the occurrence of RD in U-5 children with RR of 0.36, and OR of 0.44 and 1.68, respectively.

These studies are supported by other researches

26,27

, stating that breast milk have anti-

inflammatory bioactive factors to provide passive protection against host intestine while modulating the development of immune system. Hence, 6 monthsâ&#x20AC;&#x2122; exclusive breastmilk is recommended for every neonate.

b) Limitation of the Study The limitation of this systematic review includes the exclusion of inaccessible articles and unpublished papers. Additional limitations came from the heterogeneity of the included studies, with regard to study population and history of rotavirus vaccination in the subjects.

c) Future Application and Research Due to previous study heterogeneity, reviewers recommend future systematic review concerning about the more focused protective and risk factors from children coming from the same rotavirus vaccination background to omit other confounding factors.

Additionally, the included studies were conducted in such developing countries as Brazil, Zimbabwe, and Egypt. Being a developing and tropical country with similar characteristics, the preventable risk and recommended protective factors in this systematic review are considered suitable to be adapted in Indonesian populations.

CONCLUSION This systematic review analyses the risk and protective factors contributing to the occurrence of RD in children U-5. Based on the review, we conclude the most important risk factors such as being outside home, lack of immunity, poor hygiene and sanitation along with exclusive breastfeeding as the protective factor of RD in U-5 children. Ultimately, these preventable risk and protective factors are expected to decrease the prevalence and mortality rate of children U-5 due to RD.

REFERENCES 1. World Health Organization. Children: reducing mortality [Internet]. WHO Media Centre [cited 29 November 2017]. Available from: http://www.who.int/mediacentre/factsheets/fs178/en/ 2. World Health Organization. Weekly epidemiological record. WHO Organisation mondiale de la Sante. 2013 February, 88(5):49-64.

3. Pangesti KNA and Setiawaty V. Masa depan vaksin rotavirus di Indonesia [Internet].

Jakarta: Badan Penelitian dan Pengembangan Kesehatan. 2014 [cited 29 November 2017]. Available from: http://ejournal.litbang.depkes.go.id/index.php/MPK/article/view/3677 4. Centers for Disease Control and Prevention. Rotavirus [Internet]. Georgia: US Department of Health and Human Services. 2016 [last updated 12 August 2016; cited 30 December 2017]. Available from: https://www.cdc.gov/rotavirus/index.html 5. Sengupta P. Rotavirus: the challenges ahead. Indian J Community Med. 2009 Oct;34(4):279-82. doi: 10.4103/0970-0218.58382.

6. World Health Organization. WHO/IVB Rotavirus diseases burden estimates, April 2016. 2016 [cited 30 December 2017]. Available from: http://www.who.int/immunization/monitoring_surveillance/burden/estimates/rotaviru s/rotavirus_deaths_map_a.jpg?ua=1 7. United Nation. Goal 3: Ensure healthy lives and promote well-being for all at all ages [Internet]. [cited 30 December 2017]. Available from: http://www.un.org/sustainabledevelopment/health/ 8. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62:100612.

9. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009;6:e1000100.

10. Clements J, Rao M, Ahmed F, et al. Breast-feeding and the risk of life-threatening rotavirus diarrhea: prevention or postponement? Pediatrics. 1993 Nov;92(5):680-5.

11. Ethelberg S, Olesen B, Neimann J, et al. Risk factors for diarrhea among children in an industrialized country. Epidemilogy. 2006 Jan;17(1):24-30.

12. Nhampossa T, Mandomando I, Acacio S, et al. Diarrheal disease in rural Mozambique: burden, risk factors and etiology of diarrheal disease among children aged 0-59 months seeking care at health facilities. PLoS One. 2015 May 14;10(5):e0119824. doi: 10.1371/journal.pone.0119824.

13. Nimri LF and Hijazi S. Rotavirus-associated diarrhea in children in a refugee camp in Jordan. Journal of Diarrheal Diseases Research. 1996 March;14(1):1-4.

14. Mansour AM, Mohammady HE, Shabrawi ME, et al. Modifiable diarrhea risk factors in Egyptian children aged <5years. Epidemiol Infect. 2013 Dec;141(12):2547-59.

15. Maponga BA, Chirundu D, Gombe NT, et al. Risk factors for contracting watery diarrhea in Kadoma City, Zimbabwe, 2011: a case control study. BMC Infect Dis. 2013 Dec 2;13:567. doi: 10.1186/1471-2334-13-567.

16. Paul AB, Sonia R, Kristine LM, et al. Pathogen-specific risk factors and protective factors for acute diarrheal disease in urban Brazillian infants. The Journal of Infectious Diseases. 1993 Mar;167(3):627-32.

17. Randremanana RV, Razafindratsimandresy R, Andriatahina T, et al. Etiologies, risk factors and impact of severe diarrhea in the under-fives in Moramanga and Antananarivo, Madagascar. July 2016. PLoS ONE 11(7):e0158862. doi:10.1371/journal.pone.0158862.

18. Reves RR, Morrow AL, Barlett AV, et al. Child day care increases the risk of clinic visits for acute diarrhea and diarrhea due to rotavirus. Am J Epidemiol. 1993 Jan 1;137(1):97-107.

19. Sobel J, Gomes TA, Ramos RT, et al. Pathogen-specific risk factors and protective factors for acute diarrheal illness in children aged 12-59 months in Sao Paulo, Brazil.

Clin Infect Dis. 2004 Jun 1;38(11):1545-51.

20. Widdowson MA, van Doornum GJ, van der Poel WH, et al. An outbreak of diarrhea in a neonatal medium care unit caused by a novel strain of rotavirus: investigation using both epidemiologic and microbiological methods. Infect Control Hosp Epidemiol. 2002 Nov;23(11):665-70.

21. Immunization Action Coalition. Rotavirus: questions and answers | information about the disease and vaccines [Internet]. Minnesota: Immunization Action Coalition. [cited 30 November 2019]. Available from: http://www.immunize.org/catg.d/p4217.pdf 22. Chandran A, Fitzwater S, Zhen A, et al. Prevention of rotavirus gastroenteritis in infants and children: rotavirus vaccine safety, efficacy and potential impact of vaccines. Biologics. 200;4:213-29.

23. Raqib R, Alam DS, Sarker P, et al. Low birth weight is associated with altered immune function in rural Bangladeshi children: a birth cohort study. Am J Clin Nutr.

2007 Mar;85(3):845-52.

24. Melville JM and Moss TJ. The immune consequences of preterm birth. Front Neurosci. 2013 May 21;7:79. doi: 10.3389/fnins.2013.00079.

25. Cerini C and Aldrovandi GM. Breast milk: proactive immunomodulation and mucosal protection against viruses and other pathogens. Future virology. 2013;8(11):1127-34.

26. Arifeen S, Black RE, Antelman G, et al. Exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in Dhaka slums. Pediatrics.

2001 Oct;108(4):E67.

27. Jakaitis BM, Denning PW. Human breast milk and the gastrointestinal innate immune system. Clin Perinatol. 2014 Jun;41(2):423-35.

IMSTC 2018

Scientific Poster

Bundle of Acads AMSA-UI 2017/2018

Indonesian Medical Studentsâ&#x20AC;&#x2122; Training & Competition (IMSTC) 2018 ABSTRACT

Virgin Coconut Oil Extract as Potential Fluid Barrier Against HBV Intrapartum Transmission: A NonPharmacological Basis in Preventing Pediatric Hepatitis Andrea Laurentius1 Brenda Cristie Edina2 Lowilius Wiyoono3 1Second

Year Medical Student (085372724042, laurentiusandrea@gmail.com)

2Second

Year Medical Student (087878710098, brendacristie@hotmail.com)

3Second

Year Medical Student (081381300891, lowilius@gmail.com)

Introduction Hepatitis B virus (HBV) infection has been one of the major global health problems for years.

Half of the cases are caused by mother-to-infant transmission, especially intrapartum way, involving first-year infants, of whom 90% would develop chronic pediatric hepatitis. Urgency of Sustainable Developmental Goals in decreasing 90% HBV infection could not be achieved in 2030 through present health data extrapolation. Unfortunately, medical prevention in developing countries against HBV intrapartum transmission is still difficult to be done since they lack resources in health sectors. Thus, proposal of applying virgin coconut oil (VCO) in vagina during labor would prevent blood-fluid contact between mother and baby in order to reduce pediatric hepatitis infection.

Materials and Methods Materials for the review are obtained from several databases, such as ProQuest and Wiley with keywords conformed within MeSH thesaurus. Journal selection uses several exclusions

criteria, such as irrelevant topics or abstracts, data unavailability, incomplete discussion, and studies exceeding the last 10 years.

Results and Discussion VCO has been used as emollient and possess numerous beneficial functions related to skin barrier enhancement and antimicrobial effect on either adults or neonates. Its antiviral coating properties are also suitable to be utilized as fluid barrier to prevent HBV transmission via intrapartum pathway. In addition, lauric acid, dominant fatty acid found in the oil, serves as potent viricides. Further analyses and modification should be done to optimize the viricidal power of the oil, as well as usage convenience on vaginal mucosa.

Conclusion Hepatitis B is a liver disease that contributes to large-scale health problem worldwide, with pediatric hepatitis as one of the main concerns. Therefore, prevention of pediatric hepatitis via intrapartum transmission in developing countries could be done by using VCO on vaginal mucosa as fluid protective layer during delivery, as well as further research needed for optimization.

Indonesian Medical Students’ Training and Competition 2018

The Potential Application of Malaria Vaccine RTS,S/AS01 for Indonesian Children Angga Wiratama Lokeswara, Brian Mendel In 2016, WHO estimated that there are 216 million people infected with Malaria in 91 countries. In 2015, it is found that 70.6% of malaria mortality were in children under 5 years of age. In Indonesia, the national incidence of malaria has increased from 1.9 to 2.9% in 5 years and the prevalence of malaria in 2013 reached 6.0%. Despite the high burden of malaria in Indonesia, the prevention of malaria mainly focuses on vector control, surveillance, and at best, chemoprophylaxis. On the other hand, chemoprophylaxis agent was not being very effective prior to the rising cases of P. falciparum-resistance in Asian countries. One of the solutions to counter this problem is the malaria vaccine RTS,S/AS01 which currently undergo a phase III clinical trial. Therefore, this review has 3 main objectives: (1) Exploring the latest known clinical performance of RTS,S/AS01 vaccine; (2) Comparing RTS,S/AS01 vaccines against the current chemoprophylactic drugs; (3) Evaluating the integration of RTS,S/AS01 vaccines into the Indonesian government’s malaria eradication scheme. We searched literatures for Pubmed, Google Scholar, and ScienceDirect and reviewed 28 literatures in total and found the clinical performance of RTS,S/AS01 vaccine efficacy against clinical malaria following three primary doses are 45.1%, 35.2%, and 28.3% during 20, 32, and 48 months of follow-up, respectively. In comparing RTS,S/AS01 vaccines against the current chemoprophylactic drugs, we have come to conclusion that although the most recent trial of RTS,S/AS01 vaccine shows mediocre efficacy, it may still be the most potential prophylactic tool in Indonesia, considering that the trial was only conducted in African countries. By overcoming the current hurdles in the development of RTS,S/AS01 vaccine, we believe that with more studies, its implementation has the potential to help the Indonesian government’s efforts in eradicating malaria, and eventually, help the global community to save millions of children worldwide.

Keywords:

“RTS,S/AS01”,

“chemoprphylactic drugs”

“malaria

vaccine”,

“P.falciparum”,

“Indonesia”,

Abstract

Necessity of A New Preventive Action Towards the Neglected Modifiable Risk Factors of Childhood Diarrhea in Indonesia: A Systematic Review Fabiola Cathleen*, Christine Lieana, M. Faza Solaeman *Fabiola_cathleen@yahoo.com

Background: Diarrhea has become one of the most common health issues of children in developing countries. Globally, there are approximately 1.7 billion cases every year, which constitutes to almost 525.000 deaths, making it the second leading cause of death among children as well as a global burden. Specifically, in Indonesia, diarrhea was responsible for 31.4% deaths among children, making it the leading cause of child mortality. Moreover, based on DALY (Disability Adjusted Living Year) measurement, the years lived with disability combined with years of life lost in diarrhea exceeds each type of neoplasm. However, there are still no particular preventive measures for children diarrhea by the Indonesian government. In addition, a systematic review to show the most significant risk factors of diarrhea in Indonesia has not been done before. Based on these data, we felt the necessity of a strategic plan in accordance to the epidemiological triangle to suppress this disease.

Aim: Objectives of this systematic review are to emphasize the most predisposing risk factors contributing to diarrhea based on the epidemiological triangle, to improve the preventive measures by the society regarding the findings of the most affecting risk factors and to encourage the government in making the first diarrhea preventive program, preferred to the most vulnerable communities based on the highest risk factors found in Indonesia.

Material and method: Systematic review of observational studies was used as the method. 2607 studies were found through the PubMed Database. We then exclude records that did not meet inclusion criteria (n=2572). We further excluded another 20 studies after screening and 6 more studies in the full-text assessment of eligibility. Three reviewers then extracted data from the final total

study of 9 and scored the quality of the studies by the STROBE Statement of combined observational studies.

Results and Discussion: There are 198.959 participants from the total 9 studies. The risk factors found were divided into 3 sub categories, which were environmental, host, and others, because a good preventive measure has to meet the rule of

the epidemiological

triangle of diseases. Host category was

discussed by 44% of the studies, while the Environment category was discussed by 39%, and the remaining 17% was on the category of Others.The highest Odds Ratios were shown by child’s feces disposal in open places factor (OR=10.47) from Environmental category and child behavior of eating with hand factor (OR=5.6) from the Host category. Lower maternal education from Host category was also shown to be influential (OR=1.52). Proper disposal of child’s stool (OR=0.88), existence and less dirty sewage (OR=0.16), and household wealth (OR=0.844), were all shown to be protective factors.

Conclusion: From this systematic review, we were able to conclude that improper public disporal of child’s feces, child’s behavior of eating with hand, and low maternal education are found to be the most contributing risk factors of pediatric diarrhea in Indonesia. These findings may later be used as a foundation in instigating the first children diarrhea prevention program in Indonesia.

Diphtheria vaccination coverage in preventing outbreak Kresanti Dewi Ngadimin1, Amino Aytiwan Remedika1 1

Faculty of Medicine, Universitas Indonesia, Indonesia ABSTRACT

Introduction. Indonesia has 3203 reports of diphtheria from 2011 to 2015. Diphtheria is an acute, toxin-mediated disease caused by the bacterium Corynebacterium diphtheriae. Diphtheria is an infectious disease causing high mortality rate in children. This disease has been limited in developed countries due to vaccination. However, diphtheria is considered as a vaccinepreventable disease (VPD) and thus can be prevented. Although diphtheria occurrence has been limited in developed countries, it was still endemic in developing countries. One of the influencing factors is vaccination coverage. High vaccination coverage is possible to prevent VPD outbreaks.

Materials and methods. This poster was made by literature searching of online journals from PubMed, Scopus, and ScienceDirect. Medical textbook “Disease Control Priorities in Developing Countries” is also used as additional information. Keywords used for searching are “diphtheria”, “vaccination”, “vaccination coverage”, and “outbreak”. The information sources are limited from 2008-2017. Finally, 12 journal and 1 textbooks were used in this poster as a references.

Results. Vaccination coverage threshold depends on levels of immunity clustering. High level of immunity clustering needs much higher vaccination coverage threshold.Parents with children of immunity clustering shows lower education of VPD and vaccination and a lower trust level for the government. Mass media can be used as a media to increase vaccination education among parents as it is associated with socioeconomic status and vaccine uptake. To improve vaccine coverage, it is necessary to give education to parent about vaccination and improve Antenatal care services.

Giving vaccine after 20 years of age every 10 years is also advised as diphtheria antibodies declines with ages.

Conclusion. Poor diphtheria vaccination coverage in developing countries is likely to cause disease outbreak. Factors influencing vaccination coverage are parents' education, vaccination

services, and distance from health care services. Giving education of vaccination safety and VPD along with antenatal care for mothers may give improvement in vaccine coverage.

Keywords: Coverage; Diphteria; Outbreak; Vaccine; Vaccination Coverage

Preventable Risk Factors Associated with Community-Acquired Pneumonia among Children: Systematic Review of Large Case-Control Studies Kristian Kurniawan*, Jeremy Rafael Tandaju, Metta Dewi * kristian.k9027@gmail.com

Introduction: Children mortality is a chronic world problem. Hourly, 1050 children die, including 17 Indonesians. Pneumonia is responsible for the most etiology (13%), more than malaria, measles, and AIDS combined. Although 3 million children die yearly due to pneumonia, it still gets minimum funding, thus labeled as â&#x20AC;&#x153;The Forgotten Killer of Childrenâ&#x20AC;?. Pneumonia is classified to nosocomial and community-acquired pneumonia (CAP). CAP is extremely common among children (95%), hence we conducted a systematic review to find its risk factors.

Materials and Methods: We conduct a systematic review from case-control studies of children with CAP at Pubmed (n= 4,286). Eligible studies (n= 10) which consist of 7,588 respondents and passed inclusionexclusion criteria were evaluated with STROBE statement and studied further.

Results and Discussion: We identified top-3 risk factor group contributing to children CAP: 1) Health care system is a powerful determinant including lack of immunization recall system among GP (OR= 5.44), antibiotic usage (OR= 2.5), and usual GP absence (OR= 2.5).

2) Immune system also determines risk of children CAP. Inadequate booster: vaccine and colostrum increase the risk by 3.59 and 3.03 folds respectively. Furthermore, immunity adversary such as few hemoglobin, wasting, and unexpectedly: formulated, and cow milk increase the risk by 2.97, 2.55, 3.20, and 3.10 folds respectively.

3) Respiratory tract diseases: asthmatic children are 3.515 times more vulnerable to CAP. Other respiratory diseases: sleep-disordered breathing, empyema, and URTI enhance the risk by 3.70, 3.60, and 2.46 folds respectively.

However, limitation of our review is uneven distribution of age-specific respondents limit between studies.

Conclusion: Poor health care system, lack of immune system, and several respiratory tract diseases were agreed as main risk factors of children CAP, followed by other factors. Thus, we intend to increase awareness of caregivers and health care workers to prevent and decrease mortality rate of pneumonia, especially CAP, to achieve SDG 3.2 by 2030.

IMSTC 2018

Public Poster

Bundle of Acads AMSA-UI 2017/2018

Indonesian Medical Students’ Training and Competition 2018 PUBLIC POSTER ABSTRACT What Are You Actually Protecting?

Correcting Society’s Paradigm Towards Rubella Vaccination Brenda Cristie Edina*, Jeremy Rafael Tandaju**, Anthonius Yongko*** * 087878710098, brendacristie@hotmail.com, ** 081311541552, jrmrafael@gmail.com, *** 087774275195, anthoniuslie@gmail.com

Background Congenital Rubella Syndrome is a disease caused by Rubella Virus and is currently one of the most common infection in infants. From 2010-2015 there are 30.463 Rubella cases, 70% of which comprising people aged below 15. Rubella Virus is transmitted mostly through motherto-child during birth, a vicious cycle infecting more than one generation. Rubella commonly manifests as congenital heart diseases, cataract, and deafness; significantly decreasing children’s ability to live. There’s currently no cure to Rubella, only medication to treat clinical manifestations; which is why prevention through vaccination is really urgent.

However, society’s awareness towards the need to vaccinate is still low; even if government’s vaccination program has reached them massively. This is mainly because the wrong ongoing stigma about vaccination, rendering the society blind to facts essential for their babies’ health.

Objective Through this poster, we aim to enlighten families, especially mothers about the hazard of Rubella, and prevention by vaccination is necessary. In addition, we intend to give information about Rubella vaccination mechanism and benefits. Furthermore, we hope to break the stigma among community, that vaccination is not harmful, hence people will not be afraid to get themselves or their loved ones vaccinated in the future.

Conclusion It is very recommended for mothers to allow their child into this extremely harmless and beneficial procedure. We hope mothers and families in general will form a paradigm shift regarding vaccination or even promote vaccination in their extended family.

Meningitis Early Detection with 5S By: Ko Abel Ardana Kusuma & Johan Cahyadirga

Background Meningitis is defined as the inflammation of the meninges, which is the protective layer of the brain and spinal cord.1 Meningitis could be caused by both viral and bacterial infection.2 Compared to viral meningitis, bacterial meningitis is more severe and deadlier.2 Acute bacterial meningitis is one of the worldâ&#x20AC;&#x2122;s most common diseases infecting children and in fact, 75% of all acute bacterial meningitis occurs in children under 5 years old.3 When left untreated, meningitis may cause death in as little as a few hours.2 Furthermore, a study has shown that delayed antibiotic therapy worsens the outcome and increases the mortality rate of acute bacterial meningitis.4 To prevent this from happening, it is very important for parents to recognize signs and symptoms of meningitis early. These signs and symptoms are key symptoms for meningitis such as sudden fever, stiff neck, severe pain if leg is extended, sensitivity to light and a bulging fontanelle (soft spot on the head).2,5

Objective The aim of this poster is to raise awareness regarding meningitis, its signs and symptoms and its harmful impacts. The target audience of our poster is parents with young children. Since meningitis often strikes children, we expect parents to be able to recognize the signs and symptoms. 6

Conclusion By recognizing these symptoms early, we hope for parents to seek help from medical institutions or from a doctor as advancement to a severe form of disease reduces chances of full recovery. 6

References 1: Centers for Disease Control and Prevention. Meningitis – Home – CDC. Available from: https://www.cdc.gov/meningitis/index.html [Accessed 21st December 2017].

2: Centers for Disease Control and Prevention. Meningitis – About Bacterial Meningitis Infection – CDC. Available from: https://www.cdc.gov/meningitis/bacterial.html [Accessed 21st December 2017].

3: Agrawal S, Nadel S. Acute bacterial meningitis in infants and children: epidemiology and management.

Pediatr

Drugs.

2011

Dec

1;13(6):385-400.

Available

from:

doi:

10.2165/11593340-000000000-00000.

4: Bodilsen J, Dalanger-Pedersen M, Schønheyder HC, Nielsen H. Time to antibiotic therapy and outcome in bacterial meningitis: a Danish population-based cohort study. BMC Infect Dis. 2016; 16: 392. Available from: doi: 10.1186/s12879-016-1711-z 5: Meningitis Research Foundation.

Foundation.

Available

from:

Symptoms of Meningitis – Meningitis Research

https://www.meningitis.org/meningitis/check-symptoms

[Accessed 22nd December 2017].

6: Canadian Pediatric Society. Guidelines for the management of suspected and confirmed bacterial meningitis in Canadian children older than one month of age. Available from: https://www.cps.ca/en/documents/position/management-of-bacterial-meningitis 25th December 2017].

[Accessed

IMSTC 2018

White Paper & Videography

Bundle of Acads AMSA-UI 2017/2018

PERFECT: Preventing Pediatric Infections Valdi Ven Japranata, Nathanael, Priscilla Aya Maheswari Subroto

Background Indonesiaâ&#x20AC;&#x2122;s diphtheria cases in 2017 have been considered as an extraordinary event as it has spiked by 42 percent since 2016, causing 590 cases of which 32 children were killed. This disease could have been prevented by vaccination. However, research done by the Ministry of Health showed that 32.1 percent of children were not given complete vaccination while 8.7 percent did not get vaccinated at all.1 Lack of awareness towards vaccination leads to increased vulnerability to infection; hence, resulting in this outbreak. Regarding this problem, we, as healthcare providers and medical students need to raise the awareness of people towards getting their children and family members vaccinated, starting from our smallest circles. We conducted a small research about the knowledge of people in our environment regarding this recent event and whether they should get vaccinations. Our research shows that people are relatively still unaware of this condition and its consequences. Therefore, we want to show that as healthcare providers, our job is not limited to cure people. It is also our job to prevent such diseases by showing our love to the people around us by educating them. In addition to vaccination, we also need to remind them to improve their healthy lifestyles by having personal hygiene and balanced diet.

Objectives This video is aimed at medical students and professionals to raise the communityâ&#x20AC;&#x2122;s awareness regarding the importance of vaccination and maintaining a healthy lifestyle to prevent infectious diseases in children.

Conclusion To sum up, the role of medical students and professionals includes giving education about vaccination and healthy lifestyle to society in order to prevent infectious diseases in children.

Reference 1.

Riset Kesehatan Dasar [Internet]. 2013 [cited 29 December 2017]. Available from: www.depkes.go.id/resources/download/general/Hasil%20Riskesdas%202013.pdf

Video could be accessed through this link: https://drive.google.com/open?id=10WTCTheR1_SJcmkz_idqWr1mgV__OF3B

PCCAMSC 2018

Pre-Conference Competition Asia Medical Students Conference

AMSA-Indonesia Bundle of Acads AMSA-UI 2017/2018

PCCAMSC 2018

Scientific Poster

Bundle of Acads AMSA-UI 2017/2018

Systematic Review of Antibiotic Prophylaxis Efficacy in Clean Surgery and Minimally Invasive Surgery: A Step Towards Reducing Antimicrobial Resistance Anthonius Yongko1 Brenda Cristie Edina2 Lowilius Wiyono3 Andi Gunawan Karamoy4 1 nd

2 Year Medical Student, University of Indonesia (anthoniuslie@gmail.com, 087774275195)

2 nd

2 Year Medical Student, University of Indonesia (brendacristie@hotmail.com, 087878710098) 3 nd

2 Year Medical Student, University of Indonesia (lowilius@gmail.com, 081381300891)

4 nd

2 Year Medical Student, University of Indonesia (agkaramoy@gmail.com, 081216250107)

ABSTRACT Aim: This systematic review aims to evaluate the effectivity of prophylaxis antibiotic on clean surgery and minimally invasive surgery. Background: The use of antibiotics as preoperative prophylaxis in clean surgery has risen by 73% in the past 5 years and cause increasing resistance towards antimicrobial drugs.

However, some studies claimed the use of antibiotics are not effective to reduce surgical site infection (SSI). Methods: We did a systematic review from PubMed, Science Direct, and EBSCOHost, in which included studies were assessed by The Cochrane Collaborationâ&#x20AC;&#x2122;s Tool for assessing risk of bias and analysed qualitatively. Results and Discussion: There are 4 studies in that state the use of antibiotic prophylaxis in reducing infection are not significant, while one study contradicts the notion. Risk biases of the data are compared, and the trend shows the use of antibiotic prophylaxis in reducing infection in clean or minimally invasive surgery is not significant. In conclusion, antibiotic prophylaxis is not a requirement for these surgery. Recommendation: There are several alternatives that can be used to reduce the incidence of SSIs and antibiotic resistance in clean surgery, such as perioperative hair removal, skin preparation, maintaining normothermia, glucose control, the use of prophylactic intraoperative wound irrigation, and the use of antimicrobial sutures. Conclusion: Antibiotic prophylaxis is not a requirement for these surgery.

Variable Filariasis Endemicity

Variable Groping

MDA Compliance

Low

Not comply 41,696

Comply 7,352

High

16,299

26,737

P Prevalence Value Ratio 0.000

2.245

Association between Endemicity Level and Compliance to Mass Drug Administration for Filariasis: A Cross-sectional Study in West Papua 2015 Assyifa Gita Firdaus Faculty of Medicine Universitas Indonesia AMSA-INDONESIA Aim To identify association between Endemicity Level and Compliance to Mass Drug Administration for Filariasis Background Filariasis is a neglected tropical disease that becomes the main cause of disability in the world. Asia is the continent where most filariasis cases are found. By 2015, there were 13,032 filariasis cases in Indonesia, West Papua which has 1,244 cases is the third highest province with filariasis in Indonesia.

To eliminate filariasis, World Health Organization develops a global program namely Mass Drug Administration (MDA) by using Diethylcarbamazine (DEC) and Albendazole, single-dose, onceyearly, to be used in all endemic areas with goal of reaching 65% total population coverage for 4â&#x20AC;&#x201C;6 years.

In West Papua, the rate of filariasis endemicity varies from low to high. It was found that in low filariasis endemicity areas, the coverage of MDA was also low. Hence, it is necessary to further investigate whether there is a significant association between filariasis endemicity levels and MDA compliance.

Method Cross-sectional study design using secondary data from West Papua Health Department. Statistical analysis was done using chi-square test with Yatesâ&#x20AC;&#x2122; correction (SPSS 22.0).

Result There is significant association between filariasis endemicity level and MDA compliance (P = 0.000).

The prevalence ratio of 2.245 (95%CI: 2.216-2.273) indicates that a personâ&#x20AC;&#x2122;s risk to not comply MDA is 2.245-fold greater if he lives in area with low filariasis endemicity.

Conclusion

This study concludes that low level of filariasis endemicity is a risk for low compliance of taking MDA to the population. It is still important for low filariasis endemicty areas to comply MDA so that they do not end up as high filariasis endemicity area, a vicious cycle which can disrupt global filariasis elimination program. Thererefore, there is urgent need to improve MDA awareness by healthcare workers and community, especially in low filariasis endemicity areas.

Regional Chairperson AMSA-INDONESIA Elvira Lesmana rcindonesia@amsa-international.org +6285811240637

NOVEL MATERNAL SCREENING IMPORTANCE TOWARDS RISK FACTORS ASSOCIATED WITH NEONATAL HEPATITIS B IMMUNOPROPHYLAXIS FAILURE THROUGH VERTICAL TRANSMISSION: A SYSTEMATIC REVIEW Ariel Valentino*, Muhamad Faza Soelaeman, Adriana Viola M, Aji Wahyu W *Universitas Indonesia, tinotvs18@gmail.com

MATERIALS & METHODS

BACKGROUND According to the World Health Organization (WHO) in 2017, 257 million people worldwide are chronically infected with Hepatitis B Virus (HBV), causing more than 887,000 deaths in 2015. HBV infection during the first year of infant's life has up to 90% probability to develop into chronic infection. Many local governments and non-governmental organizations such as WHO has taken serious measures to eradicate this disease as it has become one of the main target of SDG and vaccines are obligated in many countries, including Indonesia, deploying a horde of efforts and costs. However, there are still lack of knowledge regarding the causes of immunoprophylaxis failure thus endangering those measures. Therefore, this systematic review is conducted in order to elucidate the most prevalent risk factors of immunoprophylaxis failure among HBV-infected neonates from mother-to-child transmission

Figure 2. Conceptual framework

Figure 1.Selection and analytical method

Identification of studies through PubMed Database searching (n=9) Total

Systematic Review

Records do not meet criteria (n=48)

9 Observational Cohort Studies

Records screened for eligibility (n=16)

From PubMed and Scopus Database

OBJECTIVES

Identification of studies through Scopus Database searching (n=55)

STROBE Statement

Records excluded (n=2)

Quality assessment of the studies

Objectives of this systematic review are:

Full text studies assessed for eligibility (n=14)

Qualitative Analysis

To figure out the most contributing risk factors towards hepatitis B immunoprophylaxis failure among neonates infected by mother-to-child transmission. Therefore, further actions could be conducted, such as:

Total Samples :21.983

Encouraging local governments dan non-governmental organizations towards creating an applicable screenings for infected pregnant women to prevent hepatitis B immunoprophylaxis failure

The remaining full text studies included and assessed with STROBE Statement (n=9)

Full text studies excluded, due to: 1. Study design incompatible (n=2) 2. Data not extractable (n=5)

Educating people, especially mothers, regarding immunoprophylaxis failure in Hepatitis B infection

RESULTS Distribution of factors category

Table 1. Studies characteristics with Strobe scoring AUTHOR AND YEAR OF PUBLICATION

STUDY DESIGN

STUDY LOCATION

Zou H, et al.

2012

Retrospective cohort

Beijing, China

NUMBER OF PARTICIPANTS Mothers

Infants

864

869

Wang C, et al.

2016

Prospective cohort

Jilin, China

890

871

Yin Y, et al. 2012

Prospective cohort

Taipei, Taiwan

1355

1355

Wen W-H, et al.

2013

Prospective cohort

Guangzhou, China

Zhang L, et al.

2014

Prospective cohort

Wuhan, China

METHOD OF ANALYSIS

415 case, 735 control

1150

Chengdu, China

Ding Y, et al.

2013

Prospective cohort

Shengyang, China

Lee LY, et al. 2015

Prospective cohort

Singapore, Singapore

161

161

Lu Y, et al. 2017

Prospective cohort

Jiangsu and Henan Province, China

1448

1448

172 cases, 84 control

172 cases, 84 control

4536

4536

STROBE Score (Max: 22)

Maternal HBeAg + (OR = 1,84), detectable maternal HBV DNA (OR = 1,57), maternal HBV DNA level <1 million (OR = 1) 1-9,99 million ( OR = 5,63) 10-99,9 million (OR = 2,62) >= 100 million (OR = 7,98),detectable HBV DNA in cord blood (OR = 74,43)

T-test (continuous variable), chi square (univariate analysis of odds ratio), Fisher (proportion)

Maternal HBV DNA levels (OR = 4,53)

Chi square or Fisher (categorical variable)

18.6

Maternal HBV DNA >=10^-7 (RR = 22,583), maternal HBeAg positive (RR = 31,740)

Student t-test (quantitative data), Chi-Square data, Fisher exact test (qualitative data)

17.2

Wilcoxon rank-sum test (continuous variable); chi-square test, Fisher's exact test (categorical variable), univariate and multivariate logistic regression

Positively associated = Maternal viral load (per log10-copy/ml 81 cases, 97 cases, increase) (OR Univariat = 2.54, OR Multivariat = 3.49). Negative262 controls 222 controls ly associated = increasing gestational age (OR univariat = 0.69), birth weight (per 1-kg increase) (OR univariat = 0.031)

Prospective cohort

Liu C-P, et al. 2014

OUTCOME

14.8

16.3 7

Chi-square test (categorical variables), t-test, logistic regression analysis

15.7

High maternal HBV DNA Level (per log 10 IU/mL increase) (OR univariat= 2.42, multivariat = 2.44), vaginal delivery (OR univariat = 6.52, multivariat = 6.96)

Univariate and multivariate logistic regression

17.6

Older than 20 years HBsAg positive (OR = 4,54), older than 20 years anti-HBc positive (OR = 5,69), older than 20 years anti-HBs positive (OR = 0,61)

Fisherʼs exact test

15.5

Young maternal age (RR = 6,8), HBV DNA load log IU/mL (RR = 3,8)

Fisherʼs exact test

19.8

Increasing maternal age (OR = 0,84), maternal HBV DNA load log IU/mL (OR = 3,68), maternal HBeAg (OR = 2,90)

Chi square or Fisher (categorical variable)

18.4

Mother's age <28 years (RR = 0,164), birth weight <2,500 or >=4,000 g (RR 0,443) , neonate without given HBIg (RR = 0,427)

62.5% Risk Factors

37.5% Protective Factors

20% Others

40% Agent-related Factors

6 5 4 3

40% Host-related Factors

2 1 HBV DNA HBeAg Count

Distribution according to epidemiological triangle

Young Vaginal Neonates Maternal Delivery without Age given HBIg

Numbers of journals assessing the risk factors

Figure 3. Pie charts and bar diagram of factors assessed in the study

DISCUSSIONS Limitation

From this study, we found the top 2 risk factors in term of prevalence, which are:

1. Limited study scope Coincidentally, this review only consist of observational studies, conducted in Asia. Even though Asia has the largest population infected by Hepatitis B, other region such as Africa also has a significant prevalence for the disease.

2. Insufficient sample size The limited study scope leads to lack of sample population identified in the databases.

Therefore, broader extent of studies are sugested to maximize the results

HBV DNA Load & HBeAg Zou et al (2012) explains the significance of maternal HBV DNA load to the risk of immunoprophylaxis failure. HBV DNA level of <1 million doesnʼt appear as a significant risk factor. HBV DNA level ranges, from 1 – 9,99 million, 10 – 99,9, and >= 100 million, appears as a risk factor for immunoprophylaxis failure (OR = 5,63, 2,62, 7,98, respectively). Yin et al (2012) states that HBV DNA is a major risk factor (RR = 22,583).

High HBV DNA load increases the chance of HBV infiltrating the placental barrier (Bai et al, 2007). It is also associated with the presence of HBeAg (Belopolskaya et al, 2015).

Hence, Lu et al (2017) affirms that HBeAg is a risk factor for HBV immunoprophylaxis failure. According to Pan et al. (2015), HBeAg is an immunoregulatory antigen in a human infected by HBV and may pass through the placenta. HBeAg can only be significant for HBV infection diagnosis in the presence of HBV DNA load in the maternal serum. Without HBV DNA load, the infant will lose HBeAg within 6 months of age. This is why HBV DNA load is the most common and major risk factor for HBV immunoprophylaxis failure.

Figure 4. Hepatitis B virus structure

Implication of this study 1. This study can be a basis to encourage a renewal of the previous guideline on immunopraphylaxis therapy among HBV-infected mothers and neonates, therefore sigficantly lowering the number of Hepatitis B infection cases 2. Furthermore, this study can also be used to promote HBV DNA load and HBeAg screenings in HBV-infected pregnant women.

CONCLUSION Hepatitis B immunoprophylaxis failure among mother-to-child transmitted infection are caused by a number of risk factors. This review conclude that it is mainly due to HBV DNA load and HBeAg, which are found in the maternal serum. Therefore, screenings in pregnant women regarding these factors are essential to avoid failures in order to prevent further cases of HBV infections

REFERENCES Bai, H., Zhang, L., Ma, L., Dou, X.-G., Feng, G.-H., & Zhao, G.-Z. (2007). Relationship of hepatitis B virus infection of placental barrier and hepatitis B virus intra-uterine transmission mechanism. World Journal of Gastroenterology : WJG, 13(26), 3625–3630.

Belopolskaya, M., Avrutin, V., Firsov, S., & Yakovlev, A. (2015). HBsAg level and hepatitis B viral load correlation with focus on pregnancy. Annals of Gastroenterology : Quarterly Publication of the Hellenic Society of Gastroenterology, 28(3), 379–384.

Ding, Y., Sheng, Q., Ma, L., & Dou, X. (2013). Chronic HBV infection among pregnant women and their infants in Shenyang, China. Virology Journal, 10(1), 17. https://doi.org/10.1186/1743-422x-10-17 Lee, L. Y., Aw, M., Rauff, M., Loh, K.-S., Lim, S. G., & Lee, G. H. (2015). Hepatitis B immunoprophylaxis failure and the presence of hepatitis B surface gene mutants in the affected children. Journal of Medical Virology, 87(8), 1344–1350. https://doi.org/10.1002/jmv.24193 Liu, C.-P., Zeng, Y.-L., Zhou, M., Chen, L.-L., Hu, R., Wang, L., & Tang, H. (2015). Factors Associated with Mother-to-child Transmission of Hepatitis B Virus Despite Immunoprophylaxis.

Internal Medicine, 54(7), 711–716. https://doi.org/10.2169/internalmedicine.54.3514

Lu, Y., Zhu, F.-C., Liu, J.-X., Zhai, X.-J., Chang, Z.-J., Yan, L., … Li, J. (2017). The maternal viral threshold for antiviral prophylaxis of perinatal hepatitis B virus transmission in settings with limited resources: A large prospective cohort study in China. Vaccine, 35(48), 6627–6633. https://doi.org/10.1016/j.vaccine.2017.10.032 Pan, C. Q., Duan, Z., Bhamidimarri, K. R., Zou, H., Liang, X., Li, J., & Tong, M. J. (2012). An Algorithm for Risk Assessment and Intervention of Mother to Child Transmission of Hepatitis B Virus. Clinical Gastroenterology and Hepatology, 10(5), 452–459.

Wang, C., Wang, C., Jia, Z.-F., Wu, X., Wen, S.-M., Kong, F., … Niu, J.-Q. (2016). Protective effect of an improved immunization practice of mother-to-infant transmission of hepatitis B virus and risk factors associated with immunoprophylaxis failure. Medicine, 95(34), e4390.

Wen, W.-H., Chang, M.-H., Zhao, L.-L., Ni, Y.-H., Hsu, H.-Y., Wu, J.-F., … Chen, H.-L. (2013). Mother-to-infant transmission of hepatitis B virus infection: Significance of maternal viral load and strategies for intervention. Journal of Hepatology, 59(1), 24–30.

World Health Organizatioin. (2017, July 7). Hepatitis B vaccines: WHO position paper - July 2017. Retrieved from: http://apps.who.int/iris/bitstream/handle/10665/255841/WER9227.pdf?sequence=1 Yin, Y., Wu, L., Zhang, J., Zhou, J., Zhang, P., & Hou, H. (2013). Identification of risk factors associated with immunoprophylaxis failure to prevent the vertical transmission of hepatitis B virus.

Journal of Infection, 66(5), 447–452.

Zhang, L., Gui, X., Wang, B., Ji, H., Yisilafu, R., Li, F., … Liu, X. (2014). A study of immunoprophylaxis failure and risk factors of hepatitis B virus mother-to-infant transmission. European Journal of Pediatrics, 173(9), 1161–1168. https://doi.org/10.1007/s00431-014-2305-7 Zou, H., Chen, Y., Duan, Z., Zhang, H., & Pan, C. (2011). Virologic factors associated with failure to passive-active immunoprophylaxis in infants born to HBsAg-positive mothers. Journal of Viral Hepatitis, 19(2), e18–e25.

NOVEL MATERNAL SCREENING IMPORTANCE TOWARDS RISK FACTORS ASSOCIATED WITH NEONATAL HEPATITIS B IMMUNOPROPHYLAXIS FAILURE THROUGH VERTICAL TRANSMISSION: A SYSTEMATIC REVIEW ABSTRACT Ariel Valentino, Muhamad Faza Soelaeman, Adriana Viola M, Aji Wahyu W Universitas Indonesia Aim The objective of this study is to figure out the most contributing risk factors towards Hepatitis B immunoprophylaxis failure among neonates infected by vertical transmission.

Background Hepatitis B infections are mainly through mother-to-child (vertical) transmissions and have a high risk to become chronic in later ages. Organizations, such as WHO, have taken measures to eradicate this disease by obligation of vaccines in many countries. However, these efforts are delayed by immunoprophylaxis failure caused by associable risk factors. Therefore, this systematic review is conducted to elucidate all prevalent risk factors of hepatitis B immunoprophylaxis failure among infected neonates through vertical transmission.

Material and Methods A systematic literature search was conducted in PubMed and Scopus database to identify cohort studies about risk factors contributing to immunoprophylaxis failure for HBV in mother-to-child transmissions.

There were 64 studies identified (55 in PubMed database, 9 in Scopus database) and 16 studies which met the criteria were selected. Studies other than cohort studies and lack extractable data were excluded, resulting in 9 final selected studies.

Results From 9 cohort studies, there are 21.983 participants. The common risk factors contributing to Hepatitis B immunoprophylaxis failure found in the studies were seropositivity of HBeAg (OR=1,84 and RR=31,740) and Hepatitis B virus DNA load log IU/mL (OR=2,42-7,98 and RR=22,583). More uncommon risk factors include young maternal age (RR=6,8), vaginal delivery (OR=6,52), and neonatal immunization with vaccine only (RR=0,427). Protective factors against immunoprophylaxis failure found in the studies include increase in maternal age (OR=0,84), increase in gestational age (OR=0,69), and increase in birth weight (OR=0,031-0,443).

Conclusion

Immunoprophylaxis failure of vertically transmitted hepatitis B are caused by a number of risk factors, mainly HBV DNA load and HBeAg, which are found in the maternal serum. Therefore, screenings to these factors are essential to prevent further cases of HBV infections Contact Details of Regional Chairperson Elvira Lesmana rcindonesia@amsa-international.org +6285811240637

Strategy in Enhancing Drug Compliance through Factor Identification Associated with Tu b e r c u l o s i s Tr e a t m e n t D e f a u l t A m o n g S o u t h - E a s t A s i a n : A Systematic Review of Cohort Studies Kristian Kurniawan*, Fabiola Cathleen, Marco Raditya, Johan Cahyadirga *kristian.k9027@gmail.com

RESULTS

BACKGROUND E S T I M AT E D T B I N C I D E N C E R AT E , 2 0 1 6

D I S T R I B U T I O N O F C AT E G O R I Z E D VA R I A B L E S

Incidence per 100 000 p o p u l ati o n p e r ye a r :

Table 1. Characteristi cs of Studies and STROBE’s Scoring

C at ego r i ze d Va r i abl e s

0-24 25-99 100-199

8

200-299 > 300

7

N o d ata N o t a p p l i ca b l e

6

4

4

2

Figure 1. World’s Estimated TB Incidence Rate in 2016 1

Tub e rc ul osi s ( T B ) i s a n a i r bor ne disease caused by My cobacterium tu b er c ul osi s. I t i s the wor l d’s l e a di ng cause of deat h done by a single infe ctio us a ge nt , re sul ting i n 10.4 m illion people to be infected and 1.7 mil l i o n to di e i n 2016. More tha n 9 5% of t hose cases occurred in lowa nd m i ddl e - i ncom e countri e s, wi th India as t he leading count , followed

by I n do ne si a and 5 other countr i es respo nsible for 64% of them. Indones ia i s stil l i n t he top-20 l i st of hi gh T B burden count ries in t he world, w it h t he e stim ate d tota l T B i nc i denc e rate of 391 per 100,000 population per ye a r. 1 I n 2 0 1 6 -2035 pe r i od, the United Nations’ S ustainable Developme nt G o a l s a nd WH O ’s ‘E nd T B Strategy ’, bot h aim to end t he TB epidemi c. S p e c i fi c ta rgets i nc l ude a 90% reduction of TB deat hs and 80% of TB i nci de nc e co m pa red wi th 2015. H owever, high level of t reat ment failure towa rds t he regul a r tuberc ul osi s, resulting from low patient s’ complia nce , l e a ds to the em erge nc e of more drug-resistant TB, mak ing it a worl d h e a l t h c ri si s a nd a continui ng t hreat . 1 A n e stim ate d 53 m i l l i on l i ve s t hat had been saved over t he past 16 ye a rs due to proper di a gnosi s a nd t reatment , it indicates t hat TB is a cura bl e di se a s e a nd shoul d be cont rollable. 2 On t he ot her hand, low com p l i a n c e i s one of the m a j or rea s on in TB t reat ment failure, associat e d w i th the usa ge of 5- regi m ents of TB drugs (R/H/Z/E/(S )) and long t re at me nt duration. An i nte r rupte d medication of TB result s to t he requi re me nt o f sta rting ove r a nd i nc re ased risk of developing multidrug res ista n c e T B . T hi s resul ts i n the di ffi c ult y in eradicating and cont rolling TB i nfe c tio n. M o reover, the ex i sting worldw ide program to increase drug com p l i a n c e , na m e d D OTs, onl y affe c t s t he ex ternal factors of compliance t he refo re do e s not a l ways prom ote adherence according to report by WH O. 3 The refore , we woul d l i ke to i dentif y ot her factors associated w it h dr ug co m p l i a nc e to m i ni m i ze tre atment failure in order to reduce incide nc e o f TB a nd to prevent i ts re si stancy, by mak ing a population-specifi c syste matic revi ew of fa c tors a sso ciated w it h TB patient compliance a mo ng So u t h- Ea st Asi a n that ha s not been done before. .

2

3

OBJECTIVES

To ide ntif y t he ri sk fa c tors a ssoc i ated w it h t reat ment failure in t uberculos i s am o ng st So uth-Ea st Asi a n, i n order to create an effective and efficient st rate g y a s a n i nfec tion control i n achiev ing UN’s S ustainable Developm e nt G o a l s a nd WHO ’s “ E nd T B Strategy ”.

MATERIALS & METHOD SYST E M AT I C R E V I E W Based on PRISM A Statement

1 1 CO H O RT ST UD I ES A M O NG S O UTH-EA ST A S I A N From Pu b M ed Datab ase

ST RO BE ’ S STAT E M E N T Q u ality assessment of Coh ort S tu d y

Q UA L I TAT I V E A N A LYS IS

TOTA L SA M P L ES F RO M ST UD IES 7,112 samp les

Figure 2. Selection and Analysis Method Reco rds ide ntifi e d t h ro ug h data ba s e se a rc h in g ( n= 1 4 2 3 )

Re co rds Sc re e n e d ( n= 1 0 5 )

F ul l tex t st udie s a s s e s s e d fo r e lig ib ilit y ( n= 1 3 )

To ta l inc lude d stu die s a s s e s s e d wi t h ST RO B E ’s state m e nt ( n= 1 1 )

Records excl uded ( n= 1318) No speci fic reference on Tubercul osi s on resea rch a rea Records excl uded ( n= 92) • S t u d i e s w i t h i n c o m p a ti b l e d e s i g n ( n = 2 6 ) •No assessment of TB outcome (n=20) • S t u d i e s e xc l u s i v e l y d i s c u s s i n g T B c o m p l i c a ti o n (n=18) • S t u d i e s a b o u t p r e v e n ti v e fa c t o rs o f T B ( n = 8 ) •Studies assessing treatment and diagnosis of TB (n=20)

Records excl uded ( n= 2) Insuffi ci ent i nform ation of T B outcom e a nd com pl i a nce

Figure 3. Conceptual Framework

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Gle r M T, P odew i l s LJ , M unez N , G al i p o t M , Qu e l a p i o M ID , Tu p a si TE. Im p a ct o f p a ti e n t a n d p r o g r am factors on default during treatment of multidrug-resistant tuberculosis. NT J TUBERC LUNG DIS. 2 0 1 2 ; 16( 7) : 955–60 K a p el l a B K , et al . D i r ec t l y obs er v ed tr e a tm e n t i s a sso ci a te d w i th r e d u ce d d e fa u l t a m o n g fo r e i g n tuberculosis patients in Thailand. NT J TUBERC LUNG DIS. 2009 Feb;13(2):232-37 K ip p A M , P ungr as s am i P, S t ew ar t P W, C h o n g su vi va tw o n g V, Str a u ss R P, R i e AV. Stu d y o f tu b e r cu losis and AIDS stigma as barriers to tuberculosis treatment adherence using validated stigma scales. NT J T UB E R C LU N G D I S . 2011; 5( 11) : 154 0 – 4 5 K ittik r ai s ak W, et al . F ac t or s as s oc i ate d w i th tu b e r cu l o si s tr e a tm e n t d e fa u l t a m o n g H IV- i n fe cte d tuberculosis patients in Thailand. Trans R Soc Trop Med Hyg. 2009 Jan;103(1):59-66 L ia m C K , Li m K H , Wong C M M , Tang BG. Atti tu d e s a n d kn o w l e d g e o f n e w l y d i a g n o se d tu b e r cu l o si s patients regarding the disease, and factors affecting treatment compliance. Int J Tuberc Lun Dis. 1 9 9 9 ; 3( 4) : 300- 9 P u te r a I , P ak as i TA , K ar y adi E . K no w l e d g e a n d p e r ce p ti o n o f tu b e r cu l o si s a n d th e r i sk to b e co m e treatment default among newly diagnosed pulmonary tuberculosis patients treated in primary health care, E a s t N us aTenggar a: a r et r os pec t i v e stu d y. BM C R e s N o te s. 2 0 1 5 ;8 :2 3 8 Ru th e r f or d M E , H i l l P C , M ahar ani W, Sa m p u r n o H , R u sl a m i R . R i sk fa cto r s fo r tr e a tm e n t d e fa u l t among adult tuberculosis patients in Indonesia. Int J Tuberc Lung Dis. 2013;17(10):1304-9 T h u M K , et al . H i gh t r eat m ent s uc c ess r a te a m o n g m u l ti d r u g - r e si sta n t tu b e r cu l o si s p a ti e n ts i n M yanmar, 2012–2014: a retrospective cohort study. Trans R Soc Trop Med Hyg. 2017 Sep 1;111(9):410-17.

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S h r u t hi R , J y ot hi R , P undar i k ak s ha H P, N a g e sh GN , Tu sh a r TJ. A Stu d y o f M e d i ca ti o n C o m p l i a n ce in G eriatric Patients with Chronic Illnesses at a Tertiary Care Hospital. J Clin Diagn Res. 2016 De c ;10( 12) : F C 40–3.

Ha n coc k T. T he m andal a of heal t h: a h u m a n m o d e l e co syste m . Fa m C o m m u n i ty H e a l th . 1 9 8 5 ;8 ( 3 ) :1-10.

Age

Facility

D OT s

Knowledge & Pe rc e p t i o n

Comorbidity

1

1

Smoking

Social

Race/Others/ Gender

Figure 4. Distributi on of Categorized Variables

•

The to tal s am ple s in t his rev iew we re 7 ,1 1 2 par ticipant s f ro m 1 1 inclu de d st udie s .

•

Re garding to “St re ngt he nin g t he Re po r ti ng o f O bs e r vatio nal St udie s in Epide m io lo gy ( STRO B E) State m e nt ” as s e s s m e nt , t h e b e st st u dy is co nd ucte d by P u te ra I , et al. 2 0 1 5 ( 1 9 .6 /2 2 )

•

Ris k facto r var iab le o f TB t re at m e nt d efault which are m o st d is cus s e d in m any st u die s is knowle dge and pe rce ptio n o f TB .

1

1

•

H ighe st O dd Ratio f ro m includ e d st udie s is fe ar o f lo s ing t he ir j o bs o r fe ar o f dyin g f ro m t he d is e as e ( O R: 1 2 .7 1 3 ) .

•

Pro te ctive facto rs o f tre at m e nt default include d st udy are t re at m e nt de ce nt ralizatio n ( O R: 0 .3 ) , m idd le -h igh s o cio e co n o m ic indicate d by hav ing ref r ige rato r o r TV at h o m e ( O R: 0 .3 ) , paid diagn o stic ( O R: 0 .1 4 ; 0 .2 4 ) . I n additio n, facto r as s o ciate d wit h s ucce s sf ul TB t re at m e nt is D OTs t re at m e nt ( O R: 3 .1 ) .

DISCUSSION There are several factors of low patients’ compliance and TB treatment failure, nevertheless we will discuss the top-3 factors.

Kn owl e d ge a n d p e rc e pti on of TB St u die s h ave e m ph as ize d th e m aj o r im po r tan ce o f patie nt s ’ knowle dge and pe rce ptio n towards high e r r is k o f TB t re at m e nt d efault . P ute ra I state d t hat low knowle dge o f TB car r ie d a 2 .4 9 fo ld o f in cre as e d r is k and low pe rce ptio n incre as e s t h e r is k by 5 .4 tim e s . This re latio n s hip is s up po r te d by t he fact t hat low knowle dge and pe rce ptio n o fte n le ads to co m m o n m is co n ce ptio n t hat pe rce ive d TB as in curable dis e as e , cau s e d by s in o r cu rs e , and as ham e d what o t he r m ight s ay, t he refo re re s ulting in re luctance o r re j e ctio n in fo llowing m e dical care . 1 2 A cco rdin gly, Liam C K s howe d an 1 2 .7 3 in cre as e d r is k o f t re at m e nt default re s ultin g f ro m fe ar o f lo s ing t he ir j o bs o r fe ar o f d ying. This facto r indicate s p o o r p atie nt s ’ ins ight du e to s o ciet y ’s stigm a, le ading to te nde ncy o f de nying t he d iagno s is . 1 1 The u nde r lying re as o ns m ay be f ur t h e r o r igin ate d f ro m cu lt ural be liefs , no h is to r y o f TB in fam ily, an d failure in do cto r-patie nt co m m u nicatio n . 3 , 1 2 , 1 5 This m ay be re s po ns ible fo r t h e re s ult s o f s eve r al st udie s th at state d t he ineffi cacy o f D OTS, s in ce it is o nly wo r king ex te r nally as a m e re re m ind e r. 3 A new app ro ach t hat affe ct s inte r nally, paralle l to t he he alt h co m po ne nts o f bo dy, s pir it , and m in d in as s ur ing a bette r patie nt s ’ aware ne s s and co m pliance , is ne e de d . St ud ie s s howe d t h at an im prove d do cto r-patie nt inte r pe rs o nal re latio ns h ip have a s ignifi cant infl ue n ce o n patie nts ’ bette r un de rstand ing o f t he dis e as e , cle are r e m o tio n al state an d v iew towards t he effe ct o f t he dis e as e , and high e r dr ug adh e re nce . 1 5 Pati e nt ’s Age St u die s have prove n t hat dr ug co m pliance is affe cte d by age , in which o lde r age wo uld re duce dr u g co m plian ce t hus re s ultin g in t re at m e nt failure . A cco rd ing to Thu M K , patie nt s wit h age above 5 5 has 3 .2 tim e s highe r ch an ce o f t re at m e nt failure . 1 4 M o re ove r, bas e d o n A nu nnats ir i S, patie nt s wit h age above 6 0 has 3 .1 tim e s highe r r is k. 4 I t is als o state d by C h e e C B t h at patie nt s wit h age < 6 5 ye ars o ld h as 1 .9 tim e s high e r chance fo r t re atm e nt s ucce s s . 5 A s age p ro gre s s e s , t he f unctio n al stat us als o d e cline s , in wh ich it h as be e n prove n t hat lowe re d f unctio nal stat us wo uld caus e lowe re d dr ug adh e re n ce . 1 6 A st udy by Sh r ut hi R has s hown t hat t h e num b e r o n e re as o n fo r lowe re d dr ug adhe re nce in e ld e r ly is due to fo rgetf ulne s s to take t h e m e dicatio n due to po o r re call. A no t he r is h ow s o m e e lde rs are no t cap able to take m u lti ple m e dicatio n do ne in co m plex re gim e s by t he m s e lve s . 1 7 A st udy by Pe ro n EP has s h own t h at a de cre as e d phys ical f un ctio n in g s co r m ake s it harde r fo r t h e e ld e r ly to o btain m e dicatio ns f ro m he alt hcare ce nte rs . Lack o f pro pe r aware ne s s , fam ily and s o cial s u ppo r t has als o be e n o t he r ge n e ral re as o ns fo un d. 1 6 , 1 7

Pr i m a r y H e a l t h C a re an d Faci li ti e s Patie nt ’s co m pliance i nvo l ves bo th i nterna l a nd ex ternal facto rs . A n im po rta nt ex terna l ri s k fa c to r fo r T B t re at m e nt default i s d ru g p res c ri pti o n. Patients w h o we re pre s cr ibe d m o re th a n 5 d rug s h a d a hi g her ri s k o f t re at m e nt default 7 . 2 tim es . 7 However, there i s a l s o co nd itio n whe re giv i n g fi xed do s e co m bi natio n drug s ho u ld be re co ns idered i f the patient hav i ng pa i n w hi l e swallowing , t h us it co ul d i n c rea s e 3 . 0 fo l d ri s k o f defau lt . 1 0 A no t he r ex te rn a l ri s k fa c to r i s p o o r c l i n i c a c c es s ibilit y, which incre a s es th e ri s k by 1 . 7 1 ti m es . Peo p l e who h as to walk to the c l i n i c a l s o ha s a n i nc rea s ed ri s k o f t re at m e nt d efault 4 . 5 tim es . T hi s i s s up po rted by the fact t hat walkin g is s een a s l es s des i ra bl e fo r peo pl e who are ill. M o re over, we a l s o fo und a study s how i ng t hat de ce nt ralizatio n o f ca re fo r p atients have decre as e d th e r is k s i g ni fi ca ntl y ( O R : 0 . 3 ) , beca us e i t allows patie nt s to ac c es s treatm ent ea s i er by reduc i ng t rans p o r tatio n tim e a nd co st. 13 It i s c l ea rl y s een that T B t re at m e nt co m plianc e co ul d b e i nc rea s ed by prov i di ng patie nt s wit h b ette r a c c es s to hea l thca re a nd a fi xed do s e co m binatio n drug i n pri m a r y hea l th ca re. T hes e facto rs are als o pre s ent a s a p a rt the m a nd a l a o f hea l th and co uld b e o n e o f the pi l l a rs to esta b l i s h s usta i n a bl e he alt h syste m . Th e m a nda l a o f hea l th s h ows that to affe ct an indiv idual’s hea l th, i t i s i m p o rta nt to n o t o nl y do it phar m aco lo gica l l y but a l s o by p rov i d i ng b etter phys ical e nv iro n m e nt. 18

Figure 4. Mandala of Health 1 8

The lim itatio n s o f o ur rev i ew a re th e s m a l l n um ber o f st ud ie s and t h e inabi l i ty to state the l evel o f co m pl i ance quantitati ve ly f ro m tho s e stu di es . T herefo re we refl e ct t he facto rs as s o c i ated w i th treatm ent fa i l ure to ind icate low co m p lia nc e.

CONCLUSION B as e d o n t h e syste m atic rev iew, it can be s e e n t h at 3 m o st co m m o n caus e o f t re at ment fa i l ure due to no n- co m pl i a nc e are o ld age , po o r knowle dge re garding TB and inade q uate facilit y. A s o f now, TB is o ne o f the m o st m ed i ca l l y fa c i l i tate d infe ctio n , yet TB still pe rs ist s . B as e d o n t he rev iew, it has be e n ide ntifi e d t hat fa i l ure i n T B i nfec tio n co ntro l i s a l s o due to low t re at m e nt co m pliance as s o ciate d wit h lack o f aware ne s s and m e ntal s upp o rt rega rdi n g T B i n th e s o c i ety.

The re are a lo t o f fals e stigm as re gardin g TB an d it s m e d icatio n , which co uld le ad to treatm ent fa i l u re a nd at tim es dis cr im in atio n. Pe o ple have yet to b e co ns cio us o n t he im po r tance o f f ulfi lling t he w ho l e treatm ent reg i m e a nd th e co ns e que nce s o f failin g to do s o . Thus , we s ug ge st t h at a he alt h pro m o tio n pro gra m to el uc i date k n ow l edge a nd to re ctif y t he stigm a re garding TB in s o ciet y s ho uld b e do ne in o rd e r to incre as e pe o p l e’s awa ren es s ; T B peer g ro ups s ho u ld als o be fo r m e d to incre as e m o ral s u ppo r t fo r TB p atie nt s and to ex pand bo th thei r i ns i g ht a nd co m pl i a nc e i n o rd e r to re du ce TB m o r talit y an d co nt ro l it s infe ctio n.

Strategy in Enhancing Drug Compliance through Factor Identification Associated with Tuberculosis Treatment Default Among South-East Asian: A Systematic Review of Cohort Studies Kristian Kurniawan*, Fabiola Cathleen, Marco Raditya, Johan Cahyadirga Universitas Indonesia Kristian.k9027@gmail.com

Background: Tuberculosis has become the world’s leading cause of death done by a single infectious agent, Mycobacterium tuberculosis. Indonesia holds the second highest TB infection, with 391 per 100,000 population per year. This is due to treatment failure caused by low patients’ compliance, which is associated with usage of 5-regiments TB drugs (R/H/Z/E/(S)) and long-term treatment duration, resulting in the emergence of drug-resistant TB, making it a continuous world health crisis. In addition, a population-specific systematic review of factors associated with TB patient compliance among South-East Asian has never been done before.

Aim: To identify risk factors of TB treatment failure amongst South-East Asian in order to reduce its incidence and prevent its resistancy through creating a strategy to increase patients’ compliance as an infection control Materials and Method: Systematic review was conducted on cohort studies. 1,423 studies identified from Pubmed database were screened and assessed, resulting in 11 included studies, then data extracted and evaluated according to STROBE’s Statement of Cohort Studies by 4 reviewers.

Results: Among 11 studies with total of 7,112 participants, the most discussed factor associated with TB treatment default is knowledge and perception of TB, followed by age, and primary healthcare and facilities. Factor with the highest OR is fear of losing jobs or death (OR:12.713), while treatment decentralization (OR:0.3); middle-to-high socioeconomic status (OR:0.3); paid diagnostic (OR:0.14) are protective factors. According to STROBE Statement, the best study is study conducted by Putera I in 2015 (Score:19.6/22).

Conclusion: Top 3 most common cause of treatment failure due to non-compliance are old age, poor knowledge regarding TB and inadequate facility. This indicates how the real problem in current TB infection control is the society’s false stigma on TB. Thus, we suggest that health advocation and peer groups should be made to increase knowledge and provide support for TB patients.

RISK FACTORS OF ACQUIRING HIV/AIDS AMONG SOUTHEAST ASIAN POPULATION: A SYSTEMATIC REVIEW Christine Lieana*, Ko Abel Ardana, Nathasha Brigitta, Adrianus Jonathan christinelieana@gmail.com

METHODS

INTRODUCTION Human Immunodeficiency Virus (HIV) is a virus that white blood cells specifically CD4 T Cells causing deficiency in the immune system and produce a range of clinical manifestations known as acquired immunodeficiency syndrome (AIDS). According to UNAIDS , there are 36.7 million people living with HIV in 2016 around the world, 1 million people infected died from AIDS related illnesses, and 1.8 million people are newly infected in 2016. In Southeast Asia itself, there are 3.5 million individuals in total living with HIV, 180.000 new infections, and 130.000 deaths in 2015. Although there is declining 10% in new infection and 23.5% in mortality between 2010 and 2015, there is still a high prevalent of individual living with HIV across Asia Pacific. From all age groups, adults aged 25–49 years is known to be most affected. Several known risk factors of HIV infection that contribute to its high prevalent are early sexual debut, the use of injection drugs, unprotected sex, and men who have sex with men.

In response to HIV AIDS epidemic, several measures have been made. Various global declarations and commitments with its specific objectives have been made and set by world governments since 2000. For example, The United Nations General Assembly Special Session on HIV and AIDS (UNGASS) in 2001 include a target to decrease the prevalence of HIV in adolescents aged 15–24 years globally by 25% in the end of 2010 as well as increasing young people’s access to HIV prevention information, skills, and services to 95% of those in need. By 2015, United Nation aim to combat HIV/AIDS as mentioned in their Millennium Developmental Goals.

According to UNAIDS, Treatment coverage for individuals living with HIV is 47% in Asia Pacific. This shows that the prevention and management for HIV infections can and should be improved. This review aim to assess the risk factors contributing to HIV infection which in turn can be used to give recommendation for the effective prevention especially to the most affected group.

Record identified through Pubmed database searching (n = 826)

Systematic Review

Publications did not meet inclusion criteria (n = 782)

20 Observational studies among South-east Asia

Full text articles retrieved and assessed for eligibility (n = 44)

STROBE Statement

Total Samples from Studies: 99,777 samples

Publications met exclusion criteria (n = 24)

Qualitative Analysis

Total articles used (n=20), assessed with STROBE statement

OBJECTIVES This scientific poster is aimed to assess the risk factors contributing to HIV infection among South-east Asian population, which in turn, can be used to give recommendation for the effective prevention especially to the most vulnerable group

Figure 1. Conceptual Framework

Figure 2. Selection and Analysis Method

RESULTS Table 1. Characteristics of Studies and STROBE’s Scoring AUTHOR AND YEAR OF PUBLICATION

STUDY DESIGN

STUDY LOCATION

SAMPLE SIZE

AGE

OUTCOME

METHOD OF ANALYSIS

STROBE SCORE (MAX: 22)

Le TMD, et al. 2016

Cross-sectional

Ho Chi Minh City, Vietanam

397 Men who have sex with men (MSM)

26.8 years

Age over 25 (OR:7.82); low educational level below grade 5 (OR: 2.74); Having anal sex with male partners in past month (OR: 2.7); Have sexual partners who injected drugs in past 12 months (OR: 2.24); Feel risk of HIV infection (OR: 2.42)

Multivariate analysis

13.7

25.2 years

Living in southeastern province (OR: 2.28); occupation as small bussiness/vendor (OR: 2.70), occupation as singer/barber shopper (OR: 2.48); have a religion (OR:3.56); Engaged in sex with a foreigner in past 12 months (OR: 9.24); Previously but no longer use recreational drug (OR: 7.37), currently inhaling/swallowing recreational drug (OR: 19.29), currently injecting recreational drug (OR: 63.58); recreational drug use is Amphetamine-type stimulants (OR: 28.87); recreational drug use is heroine (OR: 48.16); HIV self assessment likely to be infected (OR: 2.48); HIV self assessment very likely to be infected (OR: 3.76); syphilis positive (OR: 8.12)

Univariate analysis

15.4

Univariate and multivariate risk factors analysis

17

Nguyen TV, et al. 2016

Nadol P, et al. 2015

Le LVN, et al. 2015

Griensven FV, et al. 2013

Cross-sectional

Souther Vietnam

2768 MSM

Cross-sectional

Ho Chi Minh City, Vietnam

445 female sexual partners of male injection drug users (MWID)

30.2 years

History of injection drug use (OR 6.42); currently using opioid drugs (OR 2.03); sexual activity and behavior with the MWID within 30 days (OR: 1.32); HIV-positive status for the MWID partner (OR: 3.98); > 1 year duration of injection drug use (OR: 5.04); ≤ 1 year duration of injection drug use (OR: 2.94)

Cross-sectional

Vietnam: Hanoi, Haiphong, Quangninh, Yenbai, Danang, NghenAngiang

5298 female sex workers

30.3 years

Age 25 - 29 in high HIV prevalence province (OR: 2.75) while in low prevalence province (OR: 1.60); marital status widowed in high HIV prevalence (OR: 1.75) while in low prevalent (OR: 8.94); injection drug use in high HIV prevalence (OR: 3.44) while in low prevalent province (OR: 22.05)

Multivariate logistic regression

18.9

Bangkok

1744 homosexually active men

26 years

Receptive only or both (OR: 1.75); group sex (OR: 1.56); prior HIV testing (OR: 1.52); HSV-1 antibody(OR: 1.48); HSV-2 antibody (OR: 1.52); Treponema pallidum positivity (OR: 1.82); unemployed (OR: 1.96); nitrite inhalation (OR: 1.58), drug use for sexual pleasure (OR: 1.53), sexual coercion (OR:1.56)

Multivariate anlysis

16.5

Cohort

Quan VM, et al. 2009

Case control

Bac Ninh, Vietnam

128 MWID

27 years

Sharing drug solution through frontloading (OR: 2.75)

Multivariable logistic regression

16.8

Sheridan S, et al. 2007

Cross-sectional

Vientiane, Laos

540 men

≥ 15 years

Contemplated suicide (OR: 2.91)

Multivariate analysis

14.8

Nguyen TA, et al. 2007

Cross-sectional

Ho Chi Minh, Vietnam

600 MSM

27 years

Age 19 - 41 (OR: 4.72), education level < 6 years (OR: 2.98), only selling sex (OR: 6.12), ever injected drugs in the last 12 months (OR: 33.52), had more than five male partners for anal sex in the past month (OR: 2.55)

Logistic regression

13.5

Bivariate analysis, simple logistic, multiple logistic regression

16.9

Bivariate analysis, multivariable logistic regression

16.1

Multivariable logistic regression

20.4

Multivariate analysis

15.2

Bivariate & multivariate regression

14

Multivariable logistic regression

16.6

Perngmark P, et al. 2002

Cross-sectional

Southern Thailand

302 Injected drug users (IDU)

30 years

MAJORTIY ETHNIC THAI: Needle sharing (lifetime) (OR: 6.95), injecting immediately at drug onset (OR: 2.53), age 1st injected (OR: 2.61) MINORITY ETHNIC MALAY: Injecting immediately at drug onset (OR: 4.32), not carrying new needles (OR: 4.47)

Kim AA, et al. 2005

Cross-sectional

Battambang, Cambodia

92 women

24 years

lifetime sexual numbers > 11 partners (OR: 15), genital rash (OR: 3.5) Urban community type (OR: 2.7), formal education attained only primary (0-6 years) (OR: 1.7), age 2534 (OR: 2.1), age >35 (OR: 2.6), frequency of express and/or dressing as a woman: all the time (OR: 2.1), ever self-injected hormone (OR: 4.4), ulcerations or sores in the genital area in the past 12 months (OR: 3), didn't use online services developed for men who have sex with men/transgender in the past 6 months (OR: 1.9) age ≥ 25 (OR:1.68), ever married (OR:1.34), street-based sex worker (OR:1.34), no condom use during last sex (OR:1.45), price per sex <150000 VND(OR:1.64), >3years of sex work (OR:2.02), ever detained from rehabilitation (OR:3.25), inconsistent condom use during last month(OR:1.30), drug-injecting sex partner (OR:1.45), ever used drugs (OR:6.00), ever inject drugs (OR:4.92), perceived positive HIV infection (OR:2.65) more than 16 clients during last month(OR:2.65), drug injector(OR:6.47), have drug-injecting partner(OR:6.32) Live in province Bali (OR: 2.27), type of sex worker direct (OR: 2.54), duration of selling sex > 24 months (OR: 1.51), have siphilis (OR: 1.61)

Chimm S, et al. 2017

Cross-sectional

Phnom Penh and 12 other provinces in Cambodia

1375 sexually active transgender women

25.9 years

Le T, et al. 2015

Cross-sectional

Vietnam

5298 female sex workers

28.8 years

Tran B, et al. 2014

Cross-sectional

Mekokng Delta, Vietnam

1999 female sex workers

26.5 years

Magnani R, et al. 2010

Cross-sectional

Jakarta, Indonesia

5947 female sex workers

27 years

Morineau G, et al. 2009

Cross-sectional

Jakarta, Indonesia

1450 MSM

27 years

Use methamphetamine in last 3 months (OR: 2.69), currently infected with rectal CT or NG (OR: 2.04)

Simple & multivariate logistic regression

15

29 years

Risk factors for consistent condom with regular partners during the last 12 months: males (OR: 1.5), educational attaintment: secondary school (OR: 1.5); high school and higher (OR: 2.3), married (OR: 1.4), time since HIV status known: 2-4 years (OR: 1.4); > 5 yrs (OR: 2.4), HIV testing was voluntary (OR: 1.5), ever injected drugs (OR: 1.3), number of sex partners during last 12 months not > 2 (OR: 1.6), received condom during last 6 months (OR: 2.3)

Univariate & multivariate logistic regression

18

Multivariate analysis with logistic regression

11.6

Thanh DC, et al. 2009

Cross-sectional

Hanoi, Vietnam

4266 men and women

Khongphatthanayothin, et al. 2006

Cross-sectional

Thailand

65807 men and women

30.5-32.4 years

Age 35-39 (OR: 1.43); 30-34 (OR: 1.75); 25-29 (OR: 1.53); female (OR: 1.41), married (OR: 1.25), widowed (OR: 1.86), current residence elsewhere from Bangkok ( OR: 1.71), education: none (OR: 7.26); elementary (OR: 5); high school (OR: 3.99); college (OR: 2.43), monthly income: < 5000 Bath (OR: 1.33, profession: farmer (OR: 3.32); monk (OR: 1.4); private employee (OR: 1.29); bussines owner (OR: 1.19

Samnang P, et al. 2004

Cross-sectional

Phnom Penh, Cambodia

446 men

26 years

Port time > 1 day (OR: 3.1)

Multiple logistic regression

18

Nguyen TV, et al. 2008

Cross-sectional

Mekong Delta Province, Vietnam

406 female sex workers

26.2 years

Direct sex work (OR: 15.1); Early sexual debut ≤ 15 years old (OR: 6.8); Used illicit drugs (OR: 87.3); Trichomoniasis (OR: 11.7); Candidiasis (OR: 15.4)

Multivariate regression

16.6

Logistic regression

14.1

Khumasen N, et al. 2017

Cross-sectional

Thailand

469 MSM

19.7 years

never HIV test (OR: 1.137); partner status unknown (OR: 1.129); Age 18 never HIV tested (OR:3.163); Age 21 never HIV tested (OR: 3.160); Current regular male partner having drunk sex (OR: 2.435); never HIV tested (OR: 1.137); partner status unknown (OR: 1.129); drunk sex (OR: 1.170); cues to action in never HIV tested (OR: 1.195); partner status unknown (OR: 1.078)

VARIABLE DISTRIBUTION OF OBSERVATIONAL STUDIES • Syphilis/treponema pallidum positive • Sores in genital area in the past 12 months • Currently infected with rectal CT/NG • Trichomoniasis • Candidiasis

STD 7 studies

Drug use 12 studies

Education 5 studies Sexual factors 11 studies

• Not having any education • Education level < 6 years • Educational attaintment: • Only primary • Secondary • High school/higher

• Recreational drug use (amphetamine, heroine, opioids) • Use of injection drug (age 1st injected and duration) • Nitrite inhalation • Needle sharing • Using illicit drugs • Early sexual debut ≤ 15 years old • Sexual partners: • Who injected drugs • With HIV positive status • Male with male partner (MSM) • Number of sexual partner • Inconsistent condom use • Not using online services • Sex works • Duration of sex selling • Price per sex works

• The total of participants included were 99,777 from 20 observational studies • STROBE Statement, stands for Strengthening the Reporting of Observational Studies in Epidemiology, was used to assess the included observational studies for systematic review to improve the quality of reporting.

The best study regarding to STROBE Statement is Chimm S, et al. 2017 with score 20.4 out of 22.

• Risk factors of HIV-infection which are most discussed in studies and problematic in South-east Asia is drug use and sexual factor • Highest Odd Ratio from included studies are illicit drug use (OR: 87.3); currently injected recreational drug (OR: 63.58); (OR: 1.52).

CONCLUSION

DISCUSSION EDUCATION Studies have confirmed that level of education is associated with risk of HIV infected. According to Chimm S, participants who only took primary eduation were 1.7 times more likely to be infected compared with those with high school education. Nguyen TA also showed that participants with education level < 6 years were 2.6 times with greater risk to be infected with HIV. This has important implications for HIV programmes to ensure that poorly educated people have to be reached with education, information, communication and skills related to HIV prevention and other health-related services. On the other hand, according to Thanh DC, high education attainment was found to be significantly associated with consistent condom use with regular partners OR = 1.5 for secondary school and OR = 2.3 for high school and higher). Consistent condom use has lower risk for HIV infected.

SEXUAL TRANSMITTED DISEASE Sexual transmitted disease (STD) and sexual transmitted infection (STI) have great contribution in increasing risk of HIV infected. According to Nguyen TV, syphilis-seropositive was 8.12 times more likely to be infected by HIV. He also found that trichomoniasis and candidiasis was 11.7 and 15.4 respectively greater risk for HIV infected. Magnani R also showed that syphilis positive was 1.61 times with greater risk for HIV infected. Both of these vaginal infections increased the risk of HIV infection since they can cause vaginal inflammation , which disrupts the vaginal mucosa and increase vulnerability to HIV. These outcome was also supported by studies that conducted by Chimm S and Kim AA. According to Chimm S, history of genital sores over the previos 12 months wad 3 times more vulnerable to be infected by HIV while Kim AA found that genital rash was 3.5 more likely to be infected by HIV.

The studies show that risk factors of HIV which most discussed and problematic in South-east Asia are drug use and sexual behavior. Risk factors with highest odd ratio are illicit drug use (OR: 87.3), currently injected recreational drugs (OR: 63.58), and recreational drug use is heroin (OR: 48.16). From this systematic review, we hope that these significant risk factors of HIV infection can be used as a consideration by the government and health departments in making interventions to prevent further HIV incidence.

SEXUAL FACTORS/BEHAVIORS Several studies confirmed that there was association between sexual factors/behaviors among HIV infected. According to Le TMD, male who have anal sex with male partners in past month have 2.7 higher risk on infected by HIV. Khumasen S also showed that current regular male partner having drunk sex was 2.435 times more likely to be infected by HIV. Beside having male sex partners, number of sex partners also contribute as HIV-infected risk factors. According to Nguyan TA, had more than 5 male partners for anal sex in the past month 2.55 higher risk on infected by HIV. Tran B also found that had > 16 clients during last month increases the risk by 2.65. On the other study conducted by Chimm S, didn’t use online service provided for MSM/transgender women increases the risk by 1.9. Online service tend to provide HIV information, education and communication. According to Nguyen TV, direct sex work contributed as the most significant risk factors which increases the risk by 15.1

DRUG USE Numerous studies has been conducted regarding the interaction between drug use and HIV-infection. According to Nguyen TV, et al., currently injecting recreational drug people are 63.58 times likely to get HIV infection and heroin injection increases the risk of being HIV-infected by 48.16 times. This is because injection is one of the main method of HIV transmission. In addition, people with more than one year duration of injecting drug use are 5.04 times more vulnerable according to Nadol P, et al. A study by Tran B, et al. also observed that being a drug injector increases the risk of HIV-infection by 6.47 times. Based on a study conducted by Le LVN, et al., injection drug use made one 3.44 times and 22.05 times more prone consecutively in high HIV prevalence province and in low prevalent province. It was caused by the lesser risk of getting HIV in the low prevalence province so people tend to underestimate the probability of getting infected. Sharing drugs through frontloading has been reported to increase the risk of getting HIV by 2.75 times in a study by Quan VM, et al. Additionally, sharing drug via needle sharing increases the risk by 6.95 times in a study by Perngmark P, et al. A similar study by Thanh DC, et al. stated that the risk of being HIV-infected increased by 1.3 times in people who ever used drugs. According to Morineau G, et al., people who uses methamphetamine in last 3 months have 2.69 higher risk because it is associated with inconsistent condom use. The usage of illicit drugs increased the probability of being HIV-infected significantly by 87.3 times according to a study by Nguyen TV, et al.

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Risk Factors of Acquiring HIV/AIDS among Southeast Asian Population: A Systematic Review Christine Lieana, Ko Abel Ardana Kusuma, Nathasha B Selene, Adrianus J Sugiharta Universitas Indonesia Background: Human Immunodeficiency Virus (HIV) is a virus that attacks CD4 T cells, which depress the immune system and manifest into acquired immunodeficiency syndrome (AIDS). There were 3.5 million HIV-positive people in Southeast Asia in 2015. Adults aged 25-49 years are the most affected group of people compared to the others. Early sexual debut, use of injection drugs, unprotected sex, and men who have sex with men act as established risk factors of HIV infection that contribute to its high prevalence.

Objective: This scientific poster is aimed to assess the risk factors contributing to HIV infection among Southeast Asian population, which in turn, can provide useful recommendation for the effective prevention.

Material and method: 826 studies were searched through Pubmed database searching. Then, we eliminated publications that did not meet our inclusion criteria (n = 782). There were 44 full-text articles retrieved and assessed for eligibility: 20 of which were included in the study after assessments using exclusion criteria.

Results: 99,777 participants from 20 studies were included. In order to improve the reporting quality, STROBE Statement was used to assess the included studies for systematic review. Chimm S, et al. 2017 becomes the best study, scoring 20.4 out of 22. Drug use and sexual behaviors are the most discussed and problematic risk factors in Southeast Asia. Among drug use, the most significant risk factor is illicit drug use (OR: 87.3), while that in sexual behavior is direct sex (OR: 15.1). Risk factors with the highest odd ratio are illicit drug use (OR: 87.3), currently injected recreational drugs (OR: 63.58) with heroin as the highest recreational drug used (OR: 48.16).

Conclusion: This systematic review shows that drug use and sexual behavior are the most significant risk factors of HIV infection in Southeast Asia. The information provided in this review is expected to be used as a consideration by the government and health departments in making interventions to prevent further HIV incidence.

Preventable Risk Factors and Recommended Protective Factors Associated with Rotavirus Diarrhea among Children Under-Five: Systematic Review of Large Case-Control Study Alice Tamara*, Jeremy Rafael Tandaju, Metta Dewi, Brenda Cristie Edina Faculty of Medicine, Universitas Indonesia * alicelie_96@hotmail.com, +6281808201918 Background and Aim: Child-death is chronic health problem worldwide. Hourly, 15,000 children under-five (U-5) die â&#x20AC;&#x201C; 9% are diarrhea-based and mainly rotavirus-caused. Rotavirus diarrhea (RD) kills 453,000, including 10,888 Indonesian children annually. Although various preventions have been taken, its prevalence and mortality rate are still high. Thus, we conducted a systematic review to identify the predictor and protective factors in reducing its prevalence and mortality rate.

Method: A systematic review of large case-control studies of children under-five with RD was conducted at Pubmed and EBSCOhost (n=467). Eleven eligible studies involving 10,248 respondents were assessed with STROBEâ&#x20AC;&#x2122;s Criteria for further review.

Results and Discussion: Top-3 risk factor group contributing to U-5 RD were identified: 1) Being outside home is notably predisposing children to RD, including day-care center attendance (OR=6.0), travelling (OR=3.97), and hospitalization (OR=3.81).

2) Poor immune system which is depicted by low birth weight (OR=6.00), low maturity (OR=12.10) prematurity (OR=5.20), being wasted (OR=9.00) and consuming no breastmilk (OR=2.27), is proven to enhance the risk of RD. 3) Inadequate hygiene and sanitation expand the risk factor by having water contamination (OR=6.92), un-facilitated defecation (OR=2.7), and toilet-sharing (OR=1.6). Furthermore, left garbage (OR=3.2), no soap and towels (OR=1.6) yet determining.

Additionally, such protective factors as breastmilk feeding was found to show a favorable effect in reducing RD risk by exclusive breastfeeding (OR=0.44).

Conclusion: Being outside home, poor immunity, and inadequate hygiene and sanitation were acknowledged as major risk factors of U-5 RD, supported by other factors founded along review.

Breastmilk is agreed as main protective factor. Hence, reviewers recommend caregivers and HCW to take care of children at home, support good nutritional status of children and mother, maintain great water sanitation and promote exclusive breastmilk for every neonate. By these preventive measurements, the mortality rate of RD in children U-5 is expected to reduce.

Regional Chairperson Elvira Lesmana rcindonesia@amsa-international.org +6285811240637

I nadequat eUseofPer sonalPr ot ect i veEqui pment asaRi skFact orofSur gi calSi t eI nf ect i on Kr esant iDewiNgadi mi n,Mahar aniZai ni,Sept hendy 1 Facul t yofMedi ci ne,Uni versi t asI ndonesi a,I ndonesi a 1

I nt r oduct i on Sur gi cals i t ei nf ect i on( SSI )i soneoft he mos t common i nf ect i on wi t h pr eval enceof534% gl obal l y.

I nI ndones i a, pr eval enceofSSIi soneof t hehi ghes twi t hpr eval enceof1 0% and onl yl owert han Br azi land Vi et nam. h j k h SSIcan be caus ed by cont ami nat i on f r om ext er nal envi r onment t o t he pat i ent .

Oneoft hef act oraf f ect i ngt hi s i nci dence i si nadequat e us e ofPPE amongt heheal t hper s onnel .

However , t hi si s s ue has not been addr es s ed es peci al l yi ndevel opi ngcount r i es .

1

1

Tabl e1 .Syst emat i csear choft heusageofPPEandi nci denceofSSI

Resul t s

Obj ect i ve To r evi ew t he r el at i on bet ween us age ofPPE es peci al l yi n nur s es and t he i nci dence ofs ur ger ys i t e i nf ect i on

Mat er i alandMet hods Keywor ds: : i nf ect i on, per s onal pr ot ect i ve equi pment , s ur ger y, s ur gi cals i t ei nf ect i on

Thi s PPE usage i s af f ect ed by t he l ocalset t i ng,l ocalneeds,and r esour cel i mi t at i onsofheal t h car ef aci l i t i escombi ned wi t hi nt ensi ve educat i on,audi t i ng and sur vei l l ancest r at egi est o addr esst hi si ssue.

TheusageofPPE especi al l yi n sur gi calset t i ng i sr ecommended asi t decr easest henumberofi nci dencei npostsur gi cali nf ect i on.

Di scussi on Accor di ng t o a st udy conduct ed by Ahsan etal ,t he usage of pr ot ect i veequi pmenti sr el at edwi t hemer gi ngnumberofsur gi cal si t ei nf ect i on.However ,t he bi ggestef f ectwas shown f r om t he st udy conduct ed by Bar aka et al as i t showed si gni ficance r educt ance of sur gi calsi t ei nf ect i on r at es whenever i nf ect i on cont r olpr ogr am was i mpl ement ed.The most af f ect i ng heal t h per sonnelcor r el at i ng wi t hi nf ect i on i st henur seast heyhavet he mostexposur ewi t hpat i ent s.

Suggest i on Educat e heal t h car e per sonnel t hei mpor t anceofPPEusage Fur t herr esear ch on t her el at i on bet ween usage on PPE and i nci denceofSSI

Concl usi on PPE usage l ower st he i nci dence ofSSI I ti s suggest ed f or heal t h car e per sonnel especi al l y nur ses t o wearpr operPPE i n anysur gi cal pr ocedur e

Ref er ences

Fi gur e1 .Summar yofdat asear chi ngandi ncl usi on

1 . Baker ,A.W . ,et al( 201 6) .Epi demi ol ogy of Sur gi calSi t eI nf ect i on i n a Communi t yHospi t alNet wor k.I nf ect i onCont r ol&Hospi t alEpi demi ol ogy,37( 05) , 51 9–526.ht t ps: / / doi . or g/ 1 0.

1 01 7/ i ce.

201 6.

1 3 2.

Thu,T.( 201 6) .sur gi calsi t ei nf ect i ons:whatar et hegaps ?.Canadi anJour nalOf I nf ect i onCont r ol ,31 ( 1 ) ,1 823.ht t p: / / dx. doi . or g/ 1 0.

1 31 40/ RG. 2.

1 .

4249.

6408 3.Kennedy,L.( 201 3) .I mpl ement i ng AORN r ecommended pr act i cesf orst er i l e t echni que.

AORN Jour nal , 98( 1 ) , 1 4–23; qui z 23–26. ht t ps: / / doi . or g/ 1 0.

1 01 6/ j . aor n.

201 3.

05.

009

Asian Medical Students’ Conference 2018

Inadequate use of personal protective equipment as a risk factor of surgical site infection Kresanti Dewi Ngadimin1, Maharani Zaini1, Septhendy1 1

Faculty of Medicine, Universitas Indonesia, Indonesia

Abstract Aim. To review one of the risk factors in surgical site infection (SSI) by finding the relation between nurse knowledge on PPE and incidence of SSI. Background. Surgical site infection is one of the most common infection with prevalence of 5-34% globally. In Indonesia, prevalence of SSI is one of the highest with prevalence of 10% and only lower than Brazil and Vietnam. SSI can be caused by contamination from external environment to the patient. One of the factor affecting this incidence is inadequate use of PPE among the health personnel. However, this issue has not been addressed especially in developing countries.

Material and methods. Literature review was done systematically from reliable journal databases such as Google scholar, ProQuest, Scopus, and PubMed. Literature searching was done using “Surgical Site Infection” AND “Personal Protective Equipment”; and limited by published year, human study, topic relatability, and data availability. Finally, 9 journals were included in systematic review.

Results. Inadequate usage of PPE among health personnel especially nurses in hospital increase the incidence of SSI. PPE usage is affected by the local setting, local needs, and resource limitations of health care facilities combined with intensive education, auditing and surveillance strategies to address this issue.

The usage of PPE such as surgical mask especially in surgical setting is recommended as it decreases the number of incidence in post-surgical infection. The most affecting health personnel correlating with infection is the nurse as they have the most exposure with patients.

Conclusion. PPE usage lowers the incidence of SSI, therefore PPE usage in surgery is crucial to prevent SSI to occur. It is suggested for health care personnel especially nurses to wear proper PPE in any surgical procedure.

Keywords: infection, personal protective equipment, surgery, surgical site infection

Author Contact: Kresanti Dewi Ngadimin Kresanti.dewi@gmail.com +628135206000

Regional Chairperson Contact: Elvira Lesmana rcindonesia@amsa-international.org +6285811240637

WIW 2018

World Immunization Week 2018 AMSA International

Bundle of Acads AMSA-UI 2017/2018

WIW 2018

Scientific Article

Bundle of Acads AMSA-UI 2017/2018

Pentavalent Immunization: Enhancing Everyone with Benefits over Harms Jeremy Rafael Tandaju – AMSA-Indonesia Indonesia is the jewel of archipelago. Consisting of 17,000 islands lying over 1,905,000-meter square area and located between two oceans (The Pacific and Indian ocean) and continents (Asia and Australia), Indonesia has a lot of potential: human, nature, and lot to be developed. However, being a tropical, wide, and diverse country enhances the risk of infectious diseases which could shrink Indonesia’s chance of developing its full potential. (Indonesia Ministry of Health 2016) Therefore, Indonesia must stand and fight against various infectious diseases with high prevalence rate spread all around the archipelago.

Indonesia recently was dealing with diphtheria, and currently is one of the highest-prevalence country in the world with it. Indonesia has been one of the highest prevalence country with diphtheria. Among the last decade, 2012 has the highest incidence rate with 1,192 new cases reported, followed with reduced trend in exceeding years. Despite not considered deadly if properly treated and has an estimated vaccine coverage rate of 93,1%, there is a major outbreak in 2017, whereas estimated 32 deaths among 20 provinces are recorded up to early November 2017. About 37% of them occurred on patients who have not taken immunization before.

(Indonesia Ministry of Health 2017) In addition, pertussis is also a nation’s challenge which lower quality of life. Study found out that 1 out of 4 pertussis in babies and children will progress to pneumonia, which contributes to 13% of under-5 child’s death. In adults, pertussis, will reduce quality of life in adults with weight loss, reduced bladder control, passing out, and rib fractures which could be lethal. (World Health Organization 2015) Out of all Indonesian cases, 62% of them occurs in unimmunized patients. Beside of pertussis, tetanus is counted as burden in Indonesia. This disease could cause laryngospasm, fractures, pulmonary embolism, aspiration pneumonia, and breathing difficulty, hence causing 227 deaths of Indonesian children under-5 yearly. (Indonesia Ministry of Health 2016) Indonesia is also dealing with hepatitis B, which kills 250,000 people yearly. (World Health Organization 2018) Hepatitis B occurs on 7,1% of Indonesia’s population. It is also estimated that 10% of the occurrence will progress to liver cirrhosis and malignancy, which usually not known and diagnosed until the end-stage of its progression. Although this disease is 85% preventable by vaccine, the participation rate, especially in Indonesia are considerably low thus make this disease still a worldwide burden, including in Indonesia whose 65% of hepatitis B patient is unimmunized yet. (Indonesia Ministry of Health 2016) Quite different from majority of diseases and diseases mentioned above, pneumonia is a silent, yet a giant killer. It is usually hard to diagnosed before reaching its end-stage. Pneumonia accounted for 26,36% under5 child death in Indonesia and 13% in the world. As a world-leading children mortality cause, pneumonia kills 416 daily which one third of them due to Haemophilus influenza type B. (World Health Organization 2015) It is estimated that Haemophilus influenza type B kills 1,106 children under-5 daily due to pneumonia and meningitis.

It causes paralysis, deaf, brain damage, and respiratory failure among its host. However, 90% of them are preventable with immunization. (India Ministry of Health 2012)

Those diseases have caused hundreds of million deaths across the globe yearly. In addition, it is estimated that those diseases cause US$ 55,000,000 loss of costs yearly due to treatment and medications. (Ozawa et al.

2017) Moreover, Indonesia will face a demographic bonus of 321,000,000 populations by end of 2045. It is a big burden and let-off if Indonesia living 2045 with limited, sick, and ill person instead of having loads of productive populations which could enhance the nation’s growth rapidly. (Indonesia Ministry of Health 2016) Those diseases maybe horrifying yet dangerous, but preventable. It is estimated that the world could save US$ 350,000,000,000,000 costs and 20,000,000 child deaths by implementing immunization from 2001 to 2020.

(Ozawa et al. 2017) This even could bring the world get closer to Sustainable Development Goals (SDG) 3.8: Achieve universal health coverage, including access to safe, effective, quality and affordable essential medicines and vaccines for all. (United Nation 2016) Indonesia also realized this potential and do not want to let-off this chance, hence giving a try and action. (Indonesia Ministry of Health 2016) Indonesia has been putting effort to fight these diseases by implementing immunization recommendation calendar with various programs executed, but the participation is still considered low. (Indonesia Ministry of Health 2016) There is no sufficient yet strong data of immunization participation in Indonesia. However, data in Karanganyar, one of Indonesia’s regency shown that there are low participation ratings of hepatitis B (59,5%), DPT1 (58,1%), DPT2 (47,8%), DPT3 (45,3%), and Heamophilus influenza type B immunization (55,1%). (Anjani 2015) These facts brought us to a question: “What make the numbers so low?”. There is various reason which differs in every part of the world, some reason applied in Indonesia: Low knowledge of immunization, stigma, fears of get hurt, and indolent behavior. (Indonesia Ministry of Health 2016) The last two reasons make researchers came up with a solution: Pentavalent immunization.

Pentavalent immunization is a breakthrough which protects child from various life-threatening diseases such as diphtheria, pertussis, tetanus, hepatitis B, and Haemophilus influenza type B. It is introduced to Indonesia in 1998, when there is a joint agreement between The Dutch Government and Indonesia’s local pharmacy company, followed by its maiden clinical trial from 2003 to 2012. Pentavalent immunization finally approved and introduced as an official immunization by Indonesia’s Food and Drug Administration Agency and recommended

by Indonesian Pediatric Society in 2013. It is meant to be administered at 6th week, 10th week, and 14th week of life respectively in a form of liquid-in-vial by intra-muscular injection in anterolateral region of the mid-thigh with the help of disposable syringes. It is also recommended to be given as a booster between 15th – 18th month to enhance the immunity ability. (Hadisoemarto et al. 2016; Indonesia Ministry of Health 2016) Pentavalent immunization is much more efficient compared with five of them given separately. Firstly, it is cost efficient: Pentavalent immunization (Estimated costs US$8.10 each) is more cost efficient compared to DPT (Estimated costs US$4.15 each), Hib (Estimated costs US$5.75 each), and hepatitis B immunization (Estimated costs US$3.25 each) given separately, which cost a total US$18.00 – 2.22 times more expensive than pentavalent. (Schwartz et al. 2016) Moreover, pentavalent is significantly more comfortable for infants, which only need to experience 3 uncomfortable times of injection, compared to 9 when separated. In addition,

pentavalent give more protection to each disease compared to separated application. Pentavalent significantly increase geometric mean titer (GMT) and antibody level of diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenza type B more than independent immunizations. In addition, pentavalent proven reducing number of filamentous hemagglutinin (FHA) in pertussis, thus reducing Bordetella pertussis adherence to human respiratory cells. However, both pentavalent and independent-separated immunization successfully bring patient’s antibody level to the threshold safety level. (Merchant and Waldrop 2012) Indonesia have expanded immunization services across the archipelago, with 88% of populations admitted that health services is on their reach. Despite of its availability, reachability, and advantages by reducing immunization frequency and discomfort experiences, pentavalent administration is still low in Indonesia. It is possibly caused by lack of knowledge. A univariate study shown that 61% Indonesian still do not have adequate knowledge of immunization, especially pentavalent. Among those with no knowledge, 85% of them have not heard any information about immunization, with rest of them have heard and not understand. These facts shown that despite all the movements of vaccine education in Indonesia, including GERMAS (Gerakan masyarakat sehat = Healthy populations movement) have been held, there is still much people left untouched with those knowledges. (Anjani 2015; Indonesia Ministry of Health 2016) Besides, among those Indonesians who already have the knowledge, there is still a non-supporting force and movement against immunization. Same study proven that 81% of them is still a part of anti-immunization movement. Besides, their family is still also a problem whereas 59,3% family does not support immunization.

The shocking part is: There is still some, 13,6% health-care workers who are against immunization. They are against for several reasons: Religion (Which the diseases come and go with God’s will), stigma (There is a content in the immunization which they could not let get into their body), side effects, and many minor reasons. The current reasons apply in Indonesia is stigma that immunizations contain pig-product, which makes it considered prohibited for majority Indonesian Moslems. (Munawaroh et al. 2016) It has been clarified by Indonesian Pediatric Society that trypsin enzyme from pig is essentially needed as catalyst to break protein into peptide and amino acids, which are foods for bacteria. Bacteria will be grown and fermented, followed by polysaccharide extraction as immunization antigen. However, the following part which are purification and ultrafiltration which make the solution 1.48 x 10-11 times liquefied and becoming the final solution, which injected through the muscle. In this context, the immunization is already considered “Istihalal” (Made un-prohibited) because already rinsed for many times and for good purposes. In addition, almost every conventional religion believes that medication, including immunization is God’s extended hand to heal people in real life. Therefore, immunization give no reason for any religion to disallow it. (Indonesian Pediatric Society 2017) There is also a stigma that immunization is painful yet harmful. However, 76% of respondents admit that immunization is not as painful as they think it is. They describe it generally as being bit by an ant. The fact that pentavalent immunization is not been associated with any serious side effects also breaks the myth. Pentavalent may cause rudeness, swelling, pain, and most commonly: Fever. Around 36.8% Indonesian admitted that they

have fever after immunization, 28.1% of them have swelling at injection site, 15.5% experienced on-site pain, 10.2% unusual crying, and 9,1% on-site redness. However, those effects only last for maximum three days and not fatal nor lethal, hence making immunization is still safe to be given considering its life-protecting and lifesaving traits. (Kompally et al. 2016; Gore et al. 2016) Although it is new in Indonesia, pentavalent has proven itself as a life-saving yet efficient immunization.

Pentavalent reduce cost expenditures and administration times, thus giving more comfort to patients. Besides, increasing immunity responses and compliance of patients. However, this method face the old challenge of Indonesian: Support and stigma. It is a job and homework of holistic roles: medical students, health-care workers, stakeholders, public figures, and governments. Medical students need to embrace the community on immunization urgency and pentavalent advantages yet myth-breaking facts, thus increasing knowledge and will to get immunized.

Medical students are the core team as they are working in a large group, youthful, fully energized, with a load of ample time, and have many chances to communicate with populations such as when doing community services, organizational event, even just by waiting at a public transport station and get in a chit-chat with a random stranger. Despite commonly having less time and energy, health-care workers have a better position at educating people because of their degree, hence word is more powerful. They should have used this chance to educate and persuade people on taking pentavalent immunization, considering that most Indonesian are still unmotivated yet unsupported to get immunized. Stakeholders and government should be working together to make sure that healthcare workers and medical students are doing things right, and populations are moved to get immunized. They must work on regulations, recommendations, and support as they have the most control of media, public services, and jurisdiction.

With every people joining hands together in-order to get populations motivated, supported, and educated to take pentavalent immunization, it is believed that the administration rate will rise. Those rise in numbers will be followed by decrease of diphtheria, pertussis, tetanus, pneumonia, meningitis, hepatitis, and other diseases incidence rate, followed by prevalence, hence moving closer to SDG 3.8: Medications and vaccine for all, and overall SDG 3: Improved worldwide health. (United Nation 2016)

Bibliography Anjani, E. (2015). Level of mother knowledge of pentavalent immunization in Puntukrejo village, Karanganyar regency. Kusuma Husada School of Medicine Science, 14(2), pp.1-39.

Hadisoemarto, P., Reich, M. and Castro, M. (2016). Introduction of pentavalent vaccine in Indonesia: A policy analysis. London School of Hygiene and Tropical Medicine, 31(8), pp.1079-88.

Indonesia Health MInistry (2016). Indonesia primary health research fact sheet. 1st ed. Jakarta: Indonesia Health Ministry, pp.1-67.

Kompally, V., Kaiethala, M., Bavith, P., Prthasarati, R., Alda, N. and Puchchakayala, G. (2016). Study of adverse events following pentavalent vaccination in tertiary care hospital. Journal of Dental and Medical Sciences, 15(10), pp.38-41.

Merchant, N. and Waldrop, J. (2012). The safety advantages of pentavalent vaccines. Nurse Practitioner Journal, 37(4), pp.48-53.

Munawaroh, A., Bagus Mulyawan, S. and Widjanarko, B. (2016). Factors linked with pentavalent immunization practice in primary health care services in Salatiga regency. Indonesia Public Health Journal, 4(3), pp.94959.

Ozawa, S., Clark, S., Portnow, A., Grewal, S., Stack, M., Sinha, A. and Mirelman, A. (2017). Estimated economic impact of vaccinations in 73 low and middle income countries, 2001-2020. Journal of World Health Organization, 95(2), pp.629-38.

Raje Ss, G., Garg, Y., Jain, S. and Dahiya, A. (2016). A rare side effect to pentavalent vaccine. International Journal of Community Medicine and Public Health, 3(7), pp.1972-4.

Schwartz, K., Kwong, J., Deeks, S., Campitelli, M., Jamieson, F., Merchand-Austin, A. and Stukel, T. (2016).

Effectiveness of pertussis vaccination and duration of immunity. Canadian Medical Association Journal, 188(16), pp.399-406.

Siti Rosa, F. (2017). Does vaccine contains pig products?. [online] Indonesian Pediatric Society. Available at: http://www.idai.or.id/artikel/klinik/imunisasi/apakah-vaksin-mengandung-babi [Accessed 27 May 2018].

UNICEF (2012). Pentavalent vaccine: Guide for health workers with answers to frequently asked questions. 1st ed. Mumbai: Ministry of Health and Family Welfare Government of India, pp.1-7.

United Nations. (2018). Sustainable development goal 3: Ensure healthy lives and promote well-being for all at all ages. [online] Available at: https://sustainabledevelopment.un.org/sdg3 [Accessed 27 May 2018].

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World Health Organization. (2018). The top ten causes of death. [online] Available at: http://www.who.int/newsroom/fact-sheets/detail/the-top-10-causes-of-death [Accessed 27 May 2018].

MMR Vaccine: The Challenges in Socio-economy Factors Lowilius Wiyono â&#x20AC;&#x201C; AMSA-Indonesia Vaccination has been a program recommended by World Health Organization (WHO) since 1974. The development of vaccine has reduced the mortality number of children across the globe. This accomplishment has led to the development of Global Vaccine Action Plan (GVAP) to achieve universal immunization by 2020. This too also including Indonesia. Indonesia has conducted the Program Imunisasi Nasional (National Immunization Program) since 1977. However, after many decades, Indonesia still is one of the 10 countries with most unimmunized population which resulting in the death of 36% children by infectious disease. This also including measles and rubella. Measles is a infectious disease caused by virus and commonly infects children. Measles is one of the most contagious virus with the infection rate of 90%. Its symptoms are commonly underestimated such as fever, cough, rash and other unspecific symptoms followed by deadly complication such as pneumonia and meningitis. The same thing can be said for Rubella, which are not deadly if infect children or adults. Rubela infection only causing symptoms such as fever, headache, and athralgia. However, Rubella is one of the most serious infection if it reach pregnant women. It can infect pregnant woman and transmitted to fetus causing congenital diseases or even spontaneous abortion known as Congenital Rubella Syndrome (CRS) which contribute to many children deaths. By 2015, there are 23.164 cases of Measles and 30.643 cases of Rubella in Indonesia which of 70% are found in children below 15 years old. Throughout the years, the incidence rate of Measles and Rubella have reduced greatly. One of its benefactor is the vaccination of Measles and Rubella (MMR Vaccine) which are given to children age 9 months old and 24 months old and have been on national program since 2004. (Herliana, 2017; Pusdatin, 2016; WHO, 2012)

Figure 1. The case number of Rubella (red) and Measles (blue). Data has shown the increase of case since 2013 despite the significant reduce in the earlier years. (Kementerian Kesehatan RI, 2017)

However, after the use of MMR vaccine for more than 10 years, the number of Measles and Rubella cases each year are not capable of completely eradicate Measles and Rubella. The number has quite reduced, but risen again since 2014 following the trend of conflict concerning vaccine use. This problem is a result of reducing use of MMR vaccine in Indonesia. The government and healthcare professionals are trying to keep improving the coverage of vaccine across the country, especially by educating the society concerning the benefit of vaccine and improving its distribution to each part of Indonesia. However, this issue has not been resolved yet and still become a threat to national health. Vaccination coverage of MMR Vaccine in Indonesia are still very low.

Figure 2. The number of MMR Vaccine coverage in Indonesia from 2007-2015 (Pusdatin, 2016) Moreover, in regions such as Papua and Maluku, the coverage only reach 45-50% of all populations when WHO standardize the coverage of MMR Vaccine by 90%. It is strange that WHO data has stated Indonesia have exceeded the standard for the past decade. The coverage of MMR Vaccine only optimized around Java and its surroundings, especially Bali and South Sumatera. Moreover, Ministry of Health and Riskesdas canâ&#x20AC;&#x2122;t gather sufficient data to represent the immunization of MMR Vaccine in Indonesia. This issue might come as the government overlook one of the most crucial factors in the society, which is the socio-economy. (WHO, 2016)

Figure 3. The MMR Vaccine coverage across various regions in Indonesia. Java has been leading with the best coverage but it is not followed by other regions significantly (SEARO, 2016) Socio-economy factors in the society concerning the compliance of MMR Vaccine use are various, starting from the geography to the healthcare facilities and programs. The well-being of a family itself is also a very significant factor concerning MMR Vaccine coverage in Indonesia. The education of parents, the size of family, age, and order of birth have proven to be significant to the probability of immunized. For example, low education level can lead to short understanding of healthcare importance, especially vaccine. Education and recommendation given by government won’t be able to penetrate the difference of knowledge in an effective way. One of the issue that should be counted are also the big influence of anti-Vaccine movement in Indonesia. The lack of knowledge and education make the society prone to misleading thought, such as the idea that vaccine is not recommended by the MUI (Majelis Ulama Indonesia) or Indonesian Council of Ulama concerning its halal certification. Occupation and community surroundings are also important to fully grasp the idea and plan to decrease the level of unimmunized. (Herliana, 2017) Table 1. Socio-economy factors contributing to the compliance of vaccines in Indonesia (Herliana, 2017)

Characteristic

Detail Heavily-populated and delayed development are more prone to unimmunized

Geographic Region

population. Around 31.8% of population in Sumatera are still unimmunized while only 7.4% of population in Java are unimmunized.

Place of Residence Child’s Age Child’s Birth Order Mother’s Age

The difference between urban and rural area are not wide, however urban population has smaller number of unimmunized children.

Number of children aged 48-59 months who are not immunized have reached 26%, greater than any other age group.

Second to fourth child will most likely to not be immunized. The impact of knowledge and bad experience with side effects of vaccine may play a role.

Mother aged 25-29 are proven to have more unimmunized children up to 28.8%.

Family Size Occupation

Bigger family size (5-9 people) are proven to have low vaccine coverage. This phenomena could be caused by fund limitation to access healthcare facility.

Low-skilled occupation such as agriculture or clerical have more unimmunized children. This factor is associated with the level of education.

High frequency of exposure to media have caused lower number of vaccine

Exposure to Media

coverage. This could be caused by misleading information spread around the media (especially social media).

Healthcare resources, including wealth and insurance are leading to better

Healthcare Resources

coverage of vaccine. From the antenatal care in primary care until hospital have been associated with higher rate of compliance

In this issue, it is very crucial for the government to make a suitable regulation concerning the impact of socio-economy towards our goal to fully immunized each and every region and population. The government should not only focused on the distribution of vaccine. The improvement of life quality in the respective area should be one of the main objective in increasing the compliance of vaccine. Several programs in improving the development of the region, education especially as a means to improve life for each people, building sufficient healthcare, financial support, and of course, to deliver a well-manufactured vaccination regulation both locally or nationally. National immunization program of Indonesia has surely bring improvement in the prevention of Measles and Rubella in Indonesia. A well-established regulations which involving wide aspects of socio-economy in the society is needed to improve MMR Vaccine coverage and reach the goal of 2020 universal immunization to reduce the mortality rate of children even greater than before.

Bibliography Herliani, P. (2017). Determinants of immunization coverage of children aged 12-59 months in Indonesia: a crosssectional study. BMJ, p. 1-14.

Kementerian Kesehatan Republik Indonesia. (2017). Status campak dan rubella saat ini di Indonesia. Jakarta: Kementerian Kesehatan Republik Indonesia. p. 1-2.

World Health Organization. (2012). Surveillance guidelines for measles, rubella, and congenital rubella syndrome in the WHO European region. Denmark: WHO Regional Office for Europe. p. 8-13.

Pusat Data Informasi. (2016). Infodatin: situasi imunisasi di Indonesia. Jakarta: Kementerian Kesehatan Republik Indonesia. p. 1-4.

SEARO. (2016). EPI fact sheet: Indonesia. WHO Regional Office for South-East Asia. p. 3-4.

Academic AMSA-Universitas Indonesia 2017/2018