Diarrhea Yati

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DIARE PROF YATIE

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Diarrhea Yati

  1. 1. Yati Soenarto Deptartment of Pediatrics Gadjah Mada University/Sardjito Hospital Yogyakarta, Indonesia
  2. 3. POPULATION DENSITY IN THE WORLD Central Bureau, 2003
  3. 4. MOH, 2003 LEADING CAUSES OF DEATH IN CHILDREN U 5
  4. 5. CASE MANAGEMENT OF DIARRHEA <ul><li>Fluid and food management </li></ul><ul><li>Use of drugs </li></ul><ul><li>Communication: </li></ul><ul><li>Physicians - Patients - parents </li></ul>
  5. 6. bb Intravenous “ All” Fasting Antibiotic Antidiarrhea <ul><li>ORT: ORS </li></ul><ul><li>Limited IVbb </li></ul>Feeding : Continue during & increase after diarrhea Zn Suplementation ANTIMICROBA New formula ORS ANTIDIARRHEA Patient-Physician Communication Incidence & severity Selective Past ’ 70-’80 Present ’ 80-now Progress: management of diarrhea ANTIMICROBA ANTIDIARHEA Duration, volume &IV Most Recent Patient safety + Patient safety “ No” P-D communication
  6. 7. Problems on diarrhea case management <ul><li>ORT: </li></ul><ul><ul><li>ORS fails to reduce stool volume & duration </li></ul></ul><ul><ul><li>Not always available / acceptable </li></ul></ul><ul><ul><li>Not palatable </li></ul></ul><ul><ul><li>Too costly </li></ul></ul><ul><ul><li>Not fulfilling energy requirement </li></ul></ul><ul><li>NUTRITION : </li></ul><ul><ul><li>Loss appetite </li></ul></ul><ul><ul><li>Nutrient lost: vomit & stool losses </li></ul></ul><ul><ul><li>Loss of intestinal saccharidases  malabsorption </li></ul></ul><ul><ul><li>Withholding of food </li></ul></ul><ul><ul><li>Catabolic effect of the infection </li></ul></ul>
  7. 8. THE INCREASE OF ORT USE FOR DIARRHEA 1991 - 2000 SOURCE : Indonesian Demographic Health Survey (IDHS)
  8. 9. <ul><li>1.NGO:Coord.Board of Ped Gastr </li></ul><ul><li>Community based program </li></ul><ul><li>2.Prof.Association </li></ul><ul><li>3.Universities </li></ul><ul><li>Research development </li></ul><ul><li>Curriculum innovation </li></ul>THE ROLE OF INDONESIAN PEDIATRIC GASTROENTEROLOGY PEER GROUP <ul><li>1972 : with NGOs, Community and private sectors </li></ul><ul><li>Support program (MOH) activities : </li></ul><ul><li>1975 : Rehydration Centre at Teaching Hospitals </li></ul><ul><li> Rehydration Corner at Health Centers </li></ul><ul><li>1997 : Working group of breast feeding promotion </li></ul><ul><li>1985 :Diarrhea Training Unit (DTU)at 7 Medical Schlools </li></ul><ul><li>1986 : MEDIAC implementation to Medical Schools : 6  14  35 (all) Medical Schools  Nursing Program </li></ul><ul><li>1996 : MED-IMCI </li></ul><ul><li>2000 : </li></ul>DIARRHEA CASE MANAGEMENT
  9. 10. MCHS : Mother & Child Health Survey IDHS : Indonesian Demography & Health Survey HOME MANAGEMENT OF DIARHEA Increased fluids and continued feeding: MCHS (2003) 31,9 Urban 27,3 Rural 36,0 Continued feeding: IDHS 52,0 49,6 - Increased fluids: IDHS (2003) 56,5 57,0 96.7 * Urban 90,5 61,7 - Rural 53,5 56,5 - 1994 1997 2000
  10. 11. Drugs given by HC personal in cases with bloody & watery stool (1991-1992) 16.5 73.0 2.6 7.0 19 84 3 8 13.6 86.4 0 0 3 19 0 0 Antibiotics & antidiarrhea Antibiotics Anti Diarrhea No drugs % n % N Watery Dysentery Drugs given to 168 diarrhea attacks/ from 141 U5childen (out of 497 children living at 2 villages)
  11. 12. Studies on the etiology of Diarrhea 29 Not yet analyzed NE (not examined) 6 1 NE NE NE ’ 04 – ’05 % (n=638) 80 66 NE 2.1* 1.8* 1.3** 0 3 56 38 11.5 6 4 0.3 7.6 Enteropathogens Rotavirus ETEC (LT&ST) Salmonella Shigella Cryptosporidium E. Histolytic Mix enteropahogens ’ 90 – ’92 % (n=131) ’ 78 – ’79 % (n:338) Causative agents
  12. 13. <ul><li> : Sardjito teaching hospital: ISO 2000 2006 : Study on “Patient safety study on diarrheal disease management” . Preliminary result (n 121): </li></ul><ul><li>IV Fluids </li></ul><ul><ul><li>No dehydration: 12.3%;Vomit: 83.2% </li></ul></ul><ul><ul><li>Some dehydration: 12.7%;Vomit: 93% </li></ul></ul><ul><ul><li>Severe dehydration: 100% </li></ul></ul><ul><ul><li>Guidelines : IV Fluid only for severe dehydration & Profuse Vomit. </li></ul></ul><ul><li>Antibiotics </li></ul><ul><ul><li>Acute watery diarrhea:0.6% - Intolerance: 0% </li></ul></ul><ul><ul><li>Persistent: 75% </li></ul></ul><ul><ul><li>Dysentery: 90% </li></ul></ul><ul><ul><li>Intolerance: 0% </li></ul></ul><ul><ul><li>Guidelines : Antibiotics only for dysentery & persistent diarrhea. </li></ul></ul>
  13. 14. Courtesy of U. Parashar 1 dot = 1000 deaths GLOBAL DISTRIBUTION OF RV MORTALITY IN CHILDREN U 5
  14. 15. <ul><li>1 in 5 outpatiened; 1 in 65 hospitalized; </li></ul><ul><li>1 in 293 die due to RV; </li></ul><ul><li>20%-85% of all hospitalization of </li></ul><ul><li>children for diarrhea; </li></ul>20% of all deaths in children <5 yrs in developing countries <ul><li>U.S: $560 mill/yr, </li></ul><ul><li>& $ 200 mill loss </li></ul><ul><li>of productivity </li></ul><ul><li>PERU: $ 2.6 thsnds /yr </li></ul><ul><li>India:severe Diarrhea: $2,663/prson </li></ul>median 440,000 death in <5yrs RV Worldwide
  15. 16. Longitudinal (1/> yr) hospital studies;RV diarrhea: ‘ 80 – ‘84: 21% – 42% (8 long.studies); ‘ 78 – ‘79: 38%; Strain: G1 – G4; ’ 00 – ‘05: 53%; Strain: G1,3,4; G9 Cost: ? Deaths: Diarrhea :2 nd cause RV: ? Economic crisis Mortality Morbidity RV Indonesia
  16. 17. 1970’s 1980’s 1990’s 2000’s 30 YEARS JOURNEY (UniMelb/RCH - GMU/ Sardjito) 79 78 77 76 75 74 73 72 71 70 89 88 87 86 85 84 83 82 81 80 99 98 97 96 95 94 93 92 91 90 09 08 07 06 05 04 03 02 01 00
  17. 18. <ul><li>1973 : Rotavirus discovery (R. Bishop, RCH/Unimelb) </li></ul><ul><li>1976 : Pilot study, in which RV was found in 12% of children with acute diarrhea in Jogjakarta,Indonesia(Lancet). GMU-RCH, Introduced by J.Rohde (Rockefeller F ) </li></ul><ul><li>1976 : Asymptomatic excretion of RV (RCH, Melbourne) </li></ul><ul><li>1978 : A case control hospital & a cohort community design ( GMU-RCH )  published: </li></ul><ul><li>1979 : RV in Yogya, Indonesia – 38% of admissions – J Clin Microbiol </li></ul>
  18. 19. <ul><li>1983 : Neonatal infection shown to protect against community strains (RCH, Melbourne) </li></ul><ul><li>1989 : Funding to prepare RV3 as an oral vaccine – Flow Labs, USA (RCH) </li></ul><ul><li>1994 : Phase I trial started – funded by AMRAD (RCH) </li></ul><ul><li>1997 : Phase II trial started – funded by AMRAD & Australian Government (RCH) </li></ul>
  19. 20. <ul><li>2001 – 04 : Hospital-based system & strain surveillance for rotavirus diarrhoea and estimate of disease burden in Indonesia. A Multi Country Study on Rotavirus Surveillance, Coordinated by CDC At lanta. Funded by PATH (GMU) </li></ul><ul><li>2002 – 04 : An Extending Surveillance to Estimate the Disease Burden of Rotavirus Gastroenteritis in Yogyakarta and Central Java Indonesia (GMU) . </li></ul><ul><li>2006 – 08 : Multicenter Study (6 teaching hospitals): Extention for Hospital Based Surveillance and Strain Characterization of Rotavirus Diarrhoea in Indonesia. Funded by PATH & Biofarma (GMU) . </li></ul>
  20. 21. LONGITUDINAL RV STUDIES IN INDONESIA 1978 - 2008 20.9 All ager 287 ELISA 13 1980-1981 Jakarta Sutoto 34.8 38.1 All ages All ages 466 113 ELISA ELISA 12 12 1980-1981 1981-1982 Jakarta Simanjuntak 1.4 0 37.8 < 1 < 1 1 mo 12 yrs 42 30 334 EM, IEM & Electrophoresis of Genome RNA 13 19 78- 19 79 Yogyakarta Yati Soenarto (collaborator UniMelb) % with rotavirus Age (mos) Number Detection assay Duration (mos) Years/City Author
  21. 22. Not yet analyzed 0-60 785 ELISA On going 2005 – 2008 Multicenter surveillance Yati Soenarto collaboratorUniMelb) 31.3 34.5 36.1 42.0 0-24 0-24 0-24 113 144 319 LX LX LX 12 60 12 12 1984 1996 1997 Surabaya Soepa r to P Wasito EB 53.4 0-36 1321 ELISA 32 2001 -2004 Jogjakarta & Central Java Yati Soenarto collaborators CDC Atlanta, UniMelb) % with rotavirus Age (mos) Number Detection assay Duration (mos) Years/City Author
  22. 23. A RV STUDY IN RURAL AND URBAN HEALTH A RV STUDY IN COMMUNITY *: urban health center** : rural health center 40.9* 24.3* * 0-36 89* 86** RPHA 5 1990 Bandung Yuwono D % with Rotavirus Age (month) Number Detection Assay Duration/ months Years/ City Authors Patient Characteristics Study Characteristics 16.2 All ages 136 ELISA 13 ’ 80 – ‘81 Jakarta Sutoto Rotavirus seroprevalence Age (months) Number Detection assay Duration/ months Years/City Author Patient Characteristic s Study Characteristics
  23. 24. Hospital-based system and strain surveillance for rotavirus diarrhoea and estimate of disease burden in Indonesia. A Multi Country Study on Rotavirus Surveillance . Aug 2001 - April 2004
  24. 25. RV DISEASE BURDEN IN YOGYAKARTA AND CENTRAL JAVA (2001 – 2004)b 8929 cases of < 5 children 1397 diarrheal cases (100%) 705 rotavirus diarrhea (53.4%) 36 severe dehydration (5.1%) 2 deaths (RV positive) (0.03%) 440 dehydration (62.4%)
  25. 26. Dehydration N valid = 1397 P=0.005 N valid = 1321 P=0.024
  26. 28. Direct vs Indirect Cost 0.00 3.99 512.6 275.4 517 394 <ul><li>Total Cost </li></ul><ul><ul><li>Rotavirus + </li></ul></ul><ul><ul><li>Rotavirus - </li></ul></ul>0.08 1.77 133.2 122.1 101 84 <ul><li>Direct Non Medical Cost Expenditure </li></ul><ul><ul><li>Rotavirus + </li></ul></ul><ul><ul><li>Rotavirus - </li></ul></ul>0.00 3.77 480.1 227.8 415 310 <ul><li>Direct Medical Cost Expenditure </li></ul><ul><ul><li>Rotavirus + </li></ul></ul><ul><ul><li>Rotavirus - </li></ul></ul>P-Values t-Test Standard Deviation Mean Costs and Virus Types
  27. 29. G-type comparison: 1978-1979 and 2001-2003
  28. 30. <ul><li>Rotavirus diarrhea : </li></ul><ul><li>previous studies in Indonesia(53.4% vs 37.8%) </li></ul><ul><li>Peak age: 12-24 months; Male > female (1.4:1) </li></ul><ul><li>RV caused more dehydration significantly </li></ul><ul><li>Obvious seasonal variation: highest RV during dry season with lowest temperature. </li></ul><ul><li>Change in the RV strain circulating in Indonesia?. </li></ul><ul><li>Change in the dominant strain? </li></ul><ul><li>Where is G3? Was the G9 just recently identified? </li></ul><ul><li>G1 was the least (1 in 57) in 78-79  majority in 01-03? </li></ul><ul><li>Was non-type able In 78-79 G1? And Why? </li></ul>SUMMARY (1)
  29. 31. <ul><li>Attempts have been made to produce more representative data of RV in Indonesia. An IRSN (Indonesian Rotavirus Surveillance Network) involving 7-10 teaching hospitals & surrounding (smaller/rural/district) hospitals is being set up (Indonesian map)  followed by conducting the surveillance started at year 2006. </li></ul><ul><li>2. Current data is hospital based, is community based data required? </li></ul><ul><li>3. To ascertain the change in the strain prevalence, study of stool samples collected during that period of 1979-2001 is necessary. </li></ul>What is next??
  30. 32. EXTENTION FOR HOSPITAL-BASED SURVEILLANCE AND STRAIN CHARACTERIZATION OF ROTAVIRUS DIARRHOEA IN INDONESIA January 2006 – January 2008 Multi Center Surveillance Indonesian Rotavirus Surveillance Network (IRSN) Palembang, Jakarta, Bandung, Yogyakarta, Denpasar, Mataram
  31. 33. Palembang Jakarta Bandung Yogyakarta Denpasar Mataram Aceh Irian
  32. 34. <ul><li>INCIDENCE OF RV IN INDUSTRILIZED = IN DEVELOPING COUNTRIES  IMPROVEMENT IN: WATER SUPPLY, HYGIENE & SANITATION: NOT ↓ RV DIARRHEA  VACCINE IS NEEDED  the 2 nd breakthrough after ORT? </li></ul><ul><li>Diarrheal Disease: </li></ul><ul><li>ORT reduced mortality </li></ul><ul><li>RV vaccine reduced morbidity </li></ul>
  33. 35. COLLABORATORS
  34. 36. <ul><li>Partnership system </li></ul><ul><li>Priority research program </li></ul><ul><li>Specific projects </li></ul>Partnership & networking on research, education & clinical practice– could translational research being implemented? COMMUNITIES GOVERNMENT UNIVERSITIES International collab.& network PRODUCTS IMPROVED HEALTH/QUALITY OF LIFE Career development linkages input Out put CAPACITIES Diarrheal case management Patient safety study on Diarrheal Disease management
  35. 37. Diarrhea Cases <ul><li>Diarrhea morbidity in Indonesia at 2005 : 1.343.276 (19 provinces) </li></ul><ul><li>Diarrhea mortality in Indonesia at 2005 : 119 (14 provinces) </li></ul><ul><li>(Subdit.Ditjen Diare P4D, 2005) </li></ul><ul><li>Diarrhea morbidity in DIY at 2006 : 11.460 </li></ul><ul><li>(without Gunung Kidul) </li></ul><ul><li>(Dinkes DIY, 2006) </li></ul><ul><li>The highest morbidity : NTB  193.759 </li></ul><ul><li>The highest mortality : Sulsel  49?? </li></ul><ul><li>(Subdit.Ditjen Diare P4D, 2005) </li></ul>
  36. 38. <ul><li>Terima Kasih </li></ul>

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