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Epidemiologi

wabah
Wabah
itu apa
sih???
Kejadian berjangkitnya suatu
penyakit menular dalam
masyarakat yang jumlah
penderitanya meningkat secara
nyata melebihi dari pada
keadaan yang lazim pada waktu
dan daerah tertentu serta dapat
menimbulkan malapetaka
UU Republik Indonesia Nomor 4 Tahun
1984 tentang Wabah Penyakit Menular
dan Peraturan Pemerintah Republik Penyelidikan
Indonesia Nomor 40 Tahun 1991 Epidemiologis Pemeriksaan,
tentang Penanggulangan Wabah Pengobatan,
Penyakit Menular Perawatan, dan
Isolasi Penderita,
termasuk Tindakan
Karantina

Upaya Outbreak
Penanggulangan Managemen
Lainnya Pencegahan
di Indonesia dan
Pengebalan
Penyuluhan
kepada
Masyarakat Pemusnahan
Penanganan Penyebab
Jenazah Akibat Penyakit
Wabah
PENYELIDIKA
N
EPIDEMIOLOG
IS
• Mengetahui sebab-sebab penyakit wabah
• Menentukan faktor penyebab timbulnya wabah
• Mengetahui kelompok masyarakat yang terancam
Tujuan terkena wabah
• Menentukan cara penanggulangan

• Pengumpulan data kesakitan dan kematian penduduk


• Pemeriksaan klinis, fisik, laboratorium dan penegakan
diagnosis
Kegiatan • Pengamatan terhadap penduduk pemeriksaan
terhadap makhluk hidup lain dan benda-benda yang
ada di suatu wilayah yang diduga mengandung
penyebab penyakit wabah
Pemeriksaan, Pengobatan,
Perawatan, dan Isolasi
Penderita, termasuk
Tindakan Karantina
Dilakukan di sarana pelayanan
kesehatan, atau di tempat lain
yang ditentukan

Tujuan :
•Memberikan pertolongan medis kepada
penderita agar sembuh dan mencegah agar
mereka tidak menjadi sumber penularan
•Menemukan dan mengobati orang yang
tampaknya sehat, tetapi mengandung
penyebab penyakit sehingga secara
potensial dapat menularkan penyakit
(carrier)
Pencegahan dan
Pengebalan

Dilakukan terhadap
masyarakat yang
mempunyai risiko
terkena penyakit wabah
dengan atau tanpa
persetujuan dari orang
yang bersangkutan
Pemusnahan
Penyebab Terhadap :
Bibit penyakit/kuman
Penyakit hewan, tumbuh-tumbuhan dan atau benda
yang mengandung penyebab penyakit
Pemeriksaan
jenazah oleh
pejabat kesehatan

Penanganan
Jenazah
Akibat
Perlakuan terhadap Wabah
jenazah dan sterilisasi
bahan-bahan dan alat
yang digunakan dalam
penanganan jenazah
diawasi oleh pejabat
kesehatan
Penyuluhan kepada
Masyarakat mengenai upaya
penanggulangan wabah
dilakukan oleh pejabat
kesehatan dengan
mengikutsertakan pejabat
instansi lain, lembaga
swadaya masyarakat, pemuka
agama dan pemuka
masyarakat.
Upaya Penanggulangan Lainnya, yaitu :
tindakan tindakan khusus untuk masing-masing
penyakit, yang dilakukan dalam rangka
penanggulangan wabah
Outbreak Control by WHO

Preparedness

Detection

Confirmation

Response

Evaluation
Preparedness
• Health coordination meetings.
• Surveillance system : laporan mingguan kepada
Departemen Kesehatan dan WHO (selama terjadi
outbreak kemungkinan laporan harian daripada
mingguan)
• Rencana respon outbreak pada setiap penyakit :
sources, skills and activities yang dibutuhkan
• Persediaan : alat untuk sampling laboratorium,
antimikroba yang sesuai, cairan iv, vaksin
• Rencana untuk bangsal isolasi di rumah sakit
• Laboratorium support
Penyakit dengan potensi epidemi :

Kolera
Meningoccocal disease
Measles
Shigellosis

Pada daerah tertentu, penyakit dengan potensi


epidemi :
Malaria
Louse-borne typhus
Yellow fever
Trypanosomiasis
Visceral or cutaneous leishmaniasis
Viral haemorrhagic fevers
Relapsing fever
Typhoid
Hepatitis A dan E
Untuk memastikan deteksi cepat wabah
dalam situasi darurat, maka perlu:

• untuk mendirikan sebuah sistem


peringatan dini dalam sistem surveilans,
dengan pelaporan penyakit dengan
potensi epidemi;
• untuk melatih pekerja klinis untuk
mengenali penyakit prioritas / sindrom;
• untuk melatih pekerja klinis untuk
melaporkan kasus penyakit prioritas /
sindrom segera ke koordinator kesehatan;
• untuk koordinator kesehatan untuk
melaporkan kepada badan kesehatan
yang memimpin;
• untuk mengatur pengawasan selama
periode berisiko tinggi dan dalam daerah
yang mempunyai resiko tinggi
Setelah wabah terjadi, investigasi akan
diperlukan untuk:
• mengkonfirmasi wabah,
• mengidentifikasi semua kasus dan kontak,
• mendeteksi pola penyebaran epidemi,
• estimasi potensi untuk menyebar lebih
lanjut,
• menentukan apakah langkah-langkah kontrol
bekerja secara efektif
• peringatan dini dan meluncurkan
penyelidikan pada awal wabah
Alert • memeriksa epidemic preparedness
• memulai kampanye vaksinasi jika ada wabah
treshold di negara tetangga
• memprioritaskan daerah untuk kampanye
vaksinasi dalam outbreak

• vaksinasi massal
• mendistribusikan pengobatan ke layanan-
layanan kesehatan
Epidemic • melakukan perawatan sesuai dengan
treshold epidemic protocol
• menginformasikan kepada public
health
represen educato
tative of rs communi
the local ty
health leaders
authority
vector
health
control
specialis OCT coordina
tor
t
water/s
anitatio
clinical
n laborato worker
specialis ry
t technici
an
Respon
Investigasi
se
• Tentukan definisi kasus wabah.
• Hitung jumlah kasus dan menentukan ukuran populasi (untuk
menghitung attack rate).
• Mengumpulkan / menganalisa data deskriptif untuk tanggal (misalnya
waktu / tanggal onset, tempat / lokasi kasus dan individu karakteristik
seperti umur / seks)
• Tentukan populasi berisiko
• Merumuskan hipotesis untuk patogen / source / transmisi.
• Menindaklanjuti kasus dan kontak
• Melakukan penyelidikan lebih lanjut / studi epidemiologi (misalnya
untuk memperjelas modus transmisi, carrier, dosis yang dibutuhkan,
definisi yang lebih baik dari faktor risiko untuk penyakit dan pada
kelompok berisiko
• Menulis sebuah laporan investigasi (investigasi hasil dan rekomendasi
untuk tindakan)
Respon
se
Kontrol
• Melaksanakan pengendalian dan tindakan pencegahan
khusus untuk penyakit
• Mencegah paparan (isolasi misalnya kasus wabah
kolera)
• Mencegah infeksi (misalnya vaksinasi wabah campak)
• Mencegah penyakit (high risk group diberikan
chemoprophylaxis)
• Mencegah kematian
• Perlakukan kasus dengan pengobatan yang dianjurkan
seperti dalam pedoman WHO / nasional
OCT should :

• Bertemu setiap hari untuk update perkembangan wabah


• meninjau sumber daya manusia, logistik dan keuangan
yang tersedia untuk mengelola wabah
• mengawasi investigasi kasus yang dilaporkan untuk
mengetahui patogen, sumber infeksi dan transmisi
• memastikan bahwa para pekerja klinis melaporkan kasus-
kasus yang diduga tim dengan segera
• memastikan bahwa para pekerja menggunakan standard
treatment protocols
• memastikan bahwa kasus-kasus diukur oleh waktu dan
tempat
• menghasilkan peta spot dan kurva epidemi
• mengawasi pelaksanaan tindakan pengendalian
Resource for Outbreak
Response
Setelah sebuah wabah, tim pengendalian wabah
harus melakukan evaluasi secara menyeluruh,
sebagai berikut :

• penyebab wabah
• surveilans dan deteksi wabah
• kesiapan untuk wabah
• manajemen wabah
• kontrol tindakan
Isu-isu spesifik yang harus dievaluasi meliputi:

• ketepatan waktu deteksi dan respon


• efektivitas
• biaya
• kesempatan yang hilang
• kebijakan yang baru / direvisi
Temuan dari evaluasi ini harus
didokumentasikan dalam bentuk laporan
tertulis berisi rekomendasi yang jelas tentang:

• karakteristik epidemiologi epidemi


• surveilans
• kesiapan
• tindakan pengendalian dilakukan
The Principles of Outbreak
Epidemiology
Learning Objectives
The main motives behind this lecture
are to develop the basic concept in
investigating an epidemic, the need
to recognize the urgency behind it
and to orient the students toward
the art and science of outbreak
investigation and epidemiology.
Performance Objectives
After going through this lecture, the
students should be able to perform the
initial investigation of many smaller
outbreaks that occur so much
frequently in their vicinity that may
often pass unrecognized. Also, they
should be able to differentiate the
epidemic and the endemic fluctuations
in the frequencies of a disease.
Definitions
1. Outbreak: Sudden occurrence of an
epidemic in relatively limited
geographic area. While an outbreak is
usually limited to a small focal area,
an epidemic covers larger
geographical areas & has more than
one focal point.
2. Outbreak Epidemiology: Study of a
disease cluster or epidemic in order
to control or prevent further spread
of the disease in the population.
Field Epidemiology
A definition has been proposed by
Goodman. The essential elements are:
1. The problem is unexpected
2. An immediate response may be
necessary
3. Epidemiologists must travel to & work
on location in the field
4. The extent of investigation is likely to
be limited because of imperative for
timely intervention
Objectives of OI
1. Primary- to control the spread of
disease
2. To determine the causes of disease,
its source & mode of transmission
3. To determine who is at risk
4. To determine what exposures
predispose to disease
5. To know magnitude of the problem
Objectives continued….

6. To identify new agent


7. To determine the effectiveness of
control measures
8. To identify methods for present &
future prevention & control
9. Research & training opportunities
10. Public, Political and legal concerns
Unique aspects of OI
1. There is a pressure & urgency to
conclude the investigations quickly
which may lead to hasty decisions.
2. Data sources are often incomplete &
less accurate.
3. Decreased statistical power due to
analysis of small numbers.
4. Publicity surrounding the
investigation – community members
may have preconceived ideas.
The pace & commitment of OI
There is often a strong tendency to
collect what is “essential” in the field &
then retreat to “home” for analysis. Such
premature departure reflects lack of
concern by the public, makes any further
data collection or direct contact with the
study population difficult. Once home,
the team loses the urgency &
momentum & the sense of relevancy of
the epidemic. Don’t leave the field
without final results &
recommendations.
Trigger events & Warning Signals
1. Clustering of cases/deaths in time/space
2. Unusual increase in cases/deaths
3. Shift in age distribution of cases
4. High vector density
5. Acute hemorrhagic fever or acute fever
with renal involvement/altered
sensorium
6. Severe dehydration following diarrhea
in patients above 5 years age
7. Unusual isolate
Diseases requiring investigations
1. Endemic diseases with epidemic
potential – malaria, cholera, measles,
hepatitis, meningococcal meningitis
2. Even a single case of diseases for which
eradication/elimination goals have been
set – polio, guineaworm and yaws
3. Rare but internationally important
diseases with high case fatality rates –
yellow fever
4. Outbreaks of unknown etiology
General lines of action
The basic general lines of action during
epidemics include – Preparedness and
Interventions (investigations). Success
in dealing with an epidemic depends
largely on the state of preparedness
achieved in advance of any action. It
would be an error to consider as an
epidemic, a hitherto unrecognized
endemic situation or a mere seasonal
increase in the incidence of a disease.
Preparedness
1. Identify a nodal officer at state/district
level
2. Strengthen routine surveillance system
3. Constitute rapid response teams
4. Train medical & other health personnel
5. Prepare a list of laboratories
6. List the “high risk” pockets
7. Establish rapid communication network
8. Undertake IEC activities
9. Ensure availability of essential supplies
10.Setup inter-departmental committees
Investigations
1. Recognition & response to a request for
assistance
2. Check initial information
3. Formulate a plan of action
4. Prepare for field work
5. Confirm the existence of epidemic
6. Verify the diagnosis
7. Identify & count cases/exposed persons
8. Orient data in terms of person, place &
time
Investigations continued…..
9. Choose a study design
10.Collect specimens for lab analysis
11.Conduct environmental investigations
12.Formulate & test hypotheses
13.Implement control measures
14.Conduct additional studies
15.Prepare a written report
16.Communicate the findings
Step 1 – Recognition & Response
If the local health officials request
assistance, the regional epidemiologist
should try to acquire as much
information about the disease and the
population at risk as possible. It is also
important to find out why the request is
coming – need extra hands?, unable to
uncover the details of the disease in
question?, share the responsibility?, or
legal or ethical issues?
Step 2 – Check initial information: As
soon as the initial information on an
outbreak reaches, the regional health
coordinator must determine whether
the information is correct.
Step 3 – Formulate a plan of action: The
plan should be based on situational
analysis & taking technical, economical
& political factors into account.
Step 4 – Prepare for field work: Identify
the team members & assign
responsibilities.
Composition of typical field team
Specialists Auxillaries
1. Epidemilogist 1. Nurses
2. Clinician (pathologist) 2. Specialist assistants
3. Microbiologist 3. Secretary/Interpreter
4. Veterinarian 4. Driver
5. Entomologist
6. Mammalogist
7. Sanitary engineer
8. Toxicologist
9. Information Specialist
Step 5 – Confirm the existence
Are there cases in excess of the baseline
rate for that disease & setting? The
excess frequency should be found out
with Epidemic Threshold Curve. The
periodic frequency for previous 3 years
is plotted on a graph. Another graph at
mean + 2SD level is superimposed on it.
Any fluctuations beyond these 2 graphs
should be treated as epidemic
fluctuations (method of moving
averages).
Step 6 – Verify the diagnosis
The initial report may be spurious &
arise from misinterpretation of the
clinical features. This involves a review
of available clinical & lab findings that
supports the diagnosis. Do not apply
newly introduced, experimental or
otherwise not broadly recognized
confirmatory tests at this stage. 15-20%
of the suspected cases may be lab
confirmed.
Step 7 - Identify & count cases
Identify additional cases not known or
reported initially. The case definition
must be precise but not too exclusive..
Persons who meet the case definition
should be “line-listed”. Also, identify the
population at risk or the exposed
persons, places where the cases live,
work & have traveled to, & the possible
exposures that might have lead to the
disease.
Search for the source of infection The
main purpose here is to eliminate,
terminate or isolate the source. The
steps involved are – identify the time of
disease onset, ascertain the range of
incubation periods & look for the
source in time interval between the
maximum & the minimum IPs. In
outbreaks with person-to-person
transmission, all the contacts of the
index case are to be searched (contact
tracing).
Step 8 – Compile & Orient data
Identify when patients became ill (time),
where patients became ill (place) &
what characteristics the patients
possess (person). The earlier one can
develop such ideas, the more pertinent
& accurate data one can collect.
(a) Time: The epi-curve gives the
magnitude of outbreak, its mode of
spread & the possible duration of the
epidemic. The unit of time on X-axis are
smaller than the expected incubation
period of the disease.
(b) Place: It provides major clues
regarding the source of agent and/or
nature of exposure. Spot maps show a
pattern of distribution of cases.
(c) Person: Examine characters such as
age, sex, race, occupation or virtually
any other character that may be useful
in portraying the uniqueness of case
population.
Step 9 – Choose a Study Design
The design (Case-control, Cohort &
Case-cohort) is chosen based on size &
availability of the exposed population,
the speed with which the results are
needed & the available resources. The
study design that is chosen will then
dictate the appropriate analysis &
hypothesis testing.
Step 10 – Perform Lab analysis
It consists of collecting & testing
appropriate specimens. To identify the
etiologic agent, the collection need to be
properly timed. Examples of specimens
include - food & water, other
environmental samples (air settling
plates), and clinical (blood, stool,
sputum or wound) samples from cases &
controls.
Step 11 – Environmental Investigation

A study of environmental conditions &


the dynamics of its interaction with the
population & etiologic agents will help
to formulate the hypothesis on the
genesis of the epidemic. Such actions
assist in answering How? And Why?
questions.
Step 12 – Formulate & Test Hypothesis

As soon as the preliminary data indicate


the magnitude & severity of the
outbreak, a hypothesis should be made
regarding time, place and person; the
suspected etiological agent & the mode
of transmission. Risk specific attack
rates are calculated & compared &
relative risk/odds ratio is calculated.
Important points
1. Rare disease assumption: The OR & RR
approximate each other if the attack
rates is less than 5% but the attack rates
are much higher in outbreaks.
2. To correct for multiple comparisons, the
most effective approach is to lower the
p-value according to the number of
comparisons made.
Step 13 – Control measures
Simultaneous to data collection &
hypothesis formation, steps should be
taken to contain the epidemic. These
measures depend upon knowledge of
etiologic agent, mode of transmission &
other contributing factors. Protective
measures are necessary for patients
(isolation & disinfection), their contacts
(quarantine) and the community
Step 14 – Additional studies
Because there may be a need to find
more patients, to define better the
extent of the epidemic, or because a
new lab method or case finding
method may need to be evaluated,
the epidemiologists may want to
perform more detailed & carefully
executed studies.
Step 15 – Prepare Written Report
The final responsibility of the investigative
team is to prepare a written report to
document the investigations, findings and
the recommendations. The written report
should be submitted, in a standardized
format, to the public health authorities
including the ministry of health & remain
confidential until it has been given official
permission.
Step 16 – Communicate findings
Communicating the investigative findings
clearly is essential. All public health
officers will benefit if the experience
acquired by the investigative team is
shared by the publication of an account of
the outbreak. As a rule, the
epidemiologist informs those who
reported the first cases of the epidemic
Step 17 – Post-epidemic Measures
The efficacy of control measures should
be assessed day by day during the
outbreak, a final assessment being
made after it has ended. This will
provide a logical basis for post-epidemic
surveillance & preventive measures
aimed at avoiding the repetition of
similar outbreaks.
Bibliography
• Basu R N. Manual on Epidemiological
Surveillance Procedure for selected diseases.
National Institute of Communicable diseases.
New Delhi. 1984. 1-4.
• Bres P. Public Health Action in Emergencies
caused by Epidemics – A Practical Guide.
Geneva. WHO. 1986.
• Diane M Dwyer and Carmela Groves.
Outbreak Epidemiology. Infectious Disease
Epidemiology. 119-147.
•Epidemiologic Surveillance & Outbreak
Investigation. Textbook of Epidemiology and
Biostatistics in Preventive Medicine. W B Saunders
Publication. 43-53.
•Internet website:
www.cdc.gov/excite/classroom/outbreak.html
•Johan Giesecke. Detection and Analyses of
Outbreaks. Modern Infectious Disease
Epidemilogy. Edition 1. Arnold Publishers. Co-
published by Oxford University Press. 124-137.
•Kulkarni A P & Baride J P. Investigation of an
epidemic. Textbook of Community Medicine.
Second edition. Vora Medical Publications.
Mumbai. 159-160.
•Michael B Gregg. The principles of an epidemic
field investigation. Oxford Textbook of Public
health. Volume II – The methods of Public health.
Edition 3. Editors – Roger Detels, Walter W
Holland, James McEven, Gilbert S Omenn. Oxford
Medical Publishers. 537-545.
•Outbreak investigation and control. Training
Module. National Institute of Communicable
Diseases. New Delhi. Park K. Investigation of an
Epidemic. Park’s Textbook of preventive and
Social Medicine. Bhanot Publishers. Jabalpur.
2000. 103-104.
•Raymond S Greenberg, Stephen R Daniels, W
Dana Flanders, John William Eley, John R Boring
III. Disease Outbreaks. Medical Epidemiology.
Edition 3. Lange International Edition. Tata
McGraw Hill. 65-74.
• Reingold Arthur L. Outbreak Investigations –
a perspective. Internet website
www.cdc.gov/ncidod/eid/about.html#citation
• Robert B Wallace & Bradley N Doebbeling.
Investigation of an epidemic. Public Health
and Preventive Medicine. Maxcy-Rosenau-Last.
Edition 14. International Edition. Appleton &
Lange. 16-21.
• Vaughan J P & Morrow R H. Controlling the
Epidemic. Manual of Epidemiogy for District
Health Management. World Health
Organization. Geneva. 1989. 59-69.
References
• http://www.who.int/infectious-disease-
news/IDdocs/who cds200527/whocds200527 chapters/4
Outbreak_control.pdf

• UU Republik Indonesia Nomor 4 Tahun 1984 tentang


Wabah Penyakit Menular

• Peraturan Pemerintah Republik Indonesia Nomor 40


Tahun 1991 tentang Penanggulangan Wabah Penyakit
Menular