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DIARE PROF YATIE

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  • 1.Yati Soenarto Deptartment of Pediatrics Gadjah Mada University/Sardjito Hospital Yogyakarta, Indonesia

2. 3. POPULATION DENSITY IN THE WORLD Central Bureau, 2003 4. MOH, 2003 LEADING CAUSES OF DEATH IN CHILDREN U 5 5. CASE MANAGEMENT OF DIARRHEA

  • Fluid and food management
  • Use of drugs
  • Communication:
  • Physicians - Patients - parents

6. bb Intravenous All Fasting Antibiotic Antidiarrhea

  • ORT: ORS
  • Limited IVbb

Feeding : Continue during & increase after diarrhea Zn Suplementation ANTIMICROBA New formula ORS ANTIDIARRHEA Patient-PhysicianCommunication Incidence & severity Selective Past 70-80 Present 80-now Progress: management of diarrhea ANTIMICROBA ANTIDIARHEA Duration, volume &IVMost Recent Patient safety + Patient safety No P-D communication 7. Problems on diarrhea case management

  • ORT:
    • ORS fails to reduce stool volume & duration
    • Not always available / acceptable
    • Not palatable
    • Too costly
    • Not fulfilling energy requirement
  • NUTRITION :
    • Loss appetite
    • Nutrient lost: vomit & stool losses
    • Loss of intestinal saccharidases malabsorption
    • Withholding of food
    • Catabolic effect of the infection

8. THE INCREASE OF ORT USE FOR DIARRHEA 1991 - 2000 SOURCE : Indonesian Demographic Health Survey (IDHS) 9.

  • 1.NGO:Coord.Board of Ped Gastr
  • Community based program
  • 2.Prof.Association
  • 3.Universities
  • Research development
  • Curriculum innovation

THE ROLE OFINDONESIAN PEDIATRIC GASTROENTEROLOGY PEER GROUP

  • 1972 : with NGOs, Community and private sectors
  • Support program (MOH) activities :
  • 1975 : Rehydration Centre at Teaching Hospitals
  • Rehydration Corner at Health Centers
  • 1997 : Working group of breast feeding promotion
  • 1985 :Diarrhea Training Unit (DTU)at 7 Medical Schlools
  • 1986 : MEDIACimplementation to MedicalSchools : 61435 (all) MedicalSchoolsNursing Program
  • 1996 : MED-IMCI
  • 2000 :

DIARRHEA CASE MANAGEMENT 10. MCHS: Mother & Child Health Survey IDHS: Indonesian Demography & Health Survey HOME MANAGEMENT OF DIARHEA Increased fluids and continued feeding: MCHS (2003)31,9 Urban27,3 Rural36,0 Continued feeding: IDHS52,049,6- Increased fluids: IDHS (2003)56,557,096.7 *Urban90,561,7- Rural53,556,5- 199419972000 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 at2 villages) 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 13.

  • : Sardjito teaching hospital:ISO 2000 2006: Study onPatient safety study on diarrheal diseasemanagement .Preliminary result (n 121):
  • IV Fluids
    • No dehydration: 12.3%;Vomit: 83.2%
    • Some dehydration: 12.7%;Vomit: 93%
    • Severe dehydration: 100%
    • Guidelines : IV Fluid only for severe dehydration& Profuse Vomit.
  • Antibiotics
    • Acute watery diarrhea:0.6%- Intolerance: 0%
    • Persistent: 75%
    • Dysentery: 90%
    • Intolerance: 0%
    • Guidelines : Antibiotics only for dysentery &persistent diarrhea.

14. Courtesy of U. Parashar 1 dot = 1000 deaths GLOBAL DISTRIBUTION OF RV MORTALITY IN CHILDREN U 5 15.

  • 1 in 5 outpatiened; 1 in 65 hospitalized;
  • 1 in 293 die due to RV;
  • 20%-85% of all hospitalization of
  • children for diarrhea;

20% of all deaths in children female (1.4:1)

  • RV caused more dehydration significantly
  • Obvious seasonal variation: highest RV duringdry season with lowest temperature.
  • Change in the RV strain circulating in Indonesia?.
  • Change in the dominant strain?
  • Where is G3? Was the G9 just recently identified?
  • G1 was the least (1 in 57) in 78-79 majority in 01-03?
  • Was non-type able In 78-79 G1? AndWhy?

SUMMARY (1) 31.

  • 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.
  • 2. Current data is hospital based, is community based data required?
  • 3. To ascertain the change in the strain prevalence, study of stool samples collectedduring that period of 1979-2001 is necessary.

What is next?? 32. EXTENTION FORHOSPITAL-BASED SURVEILLANCEAND STRAIN CHARACTERIZATIONOF ROTAVIRUS DIARRHOEAIN INDONESIA January 2006 January 2008 Multi Center Surveillance Indonesian Rotavirus Surveillance Network (IRSN) Palembang, Jakarta, Bandung, Yogyakarta, Denpasar, Mataram 33. Palembang Jakarta Bandung Yogyakarta Denpasar Mataram Aceh Irian 34.

  • INCIDENCE OF RV IN INDUSTRILIZED = IN DEVELOPING COUNTRIES IMPROVEMENT IN: WATER SUPPLY, HYGIENE & SANITATION:NOT RV DIARRHEA VACCINE IS NEEDEDthe 2 ndbreakthrough after ORT?
  • Diarrheal Disease:
  • ORT reduced mortality
  • RV vaccine reduced morbidity

35. COLLABORATORS 36.

  • Partnership system
  • Priority research program
  • Specific projects

Partnership & networking on research, education & clinical practice could translational research being implemented? COMMUNITIES GOVERNMENT UNIVERSITIES International collab.& networkPRODUCTS IMPROVED HEALTH/QUALITY OF LIFE Career development linkages input Out put CAPACITIES Diarrheal case management Patient safety studyon Diarrheal Disease management 37. Diarrhea Cases

  • Diarrhea morbidity in Indonesia at 2005 : 1.343.276 (19 provinces)
  • Diarrhea mortality in Indonesia at 2005 : 119 (14 provinces)
  • (Subdit.Ditjen Diare P4D, 2005)
  • Diarrhea morbidity in DIY at 2006 : 11.460
  • (without Gunung Kidul)
  • (Dinkes DIY, 2006)
  • The highest morbidity : NTB193.759
  • The highest mortality : Sulsel49??
  • (Subdit.Ditjen Diare P4D, 2005)

38.

  • Terima Kasih