Diarrhea Yati
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Transcript of Diarrhea Yati
DIARRHEA AS A MAJOR PROBLEM IN PEDIATRCS
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Yati SoenartoDeptartment of Pediatrics
Gadjah Mada University/Sardjito HospitalYogyakarta, Indonesia
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
POPULATION DENSITY IN THE WORLD
Central Bureau, 2003
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
0
5
10
15
20
25
30
35
ARI diarrhoea nervoussystem
parasitic& otherinfection
tetanus thyphoid
1995
2000
MOH, 2003
LEADING CAUSES OF DEATHIN CHILDREN U 5
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
CASE MANAGEMENT OF DIARRHEACASE MANAGEMENT OF DIARRHEACASE MANAGEMENT OF DIARRHEACASE MANAGEMENT OF DIARRHEA
1. Fluid and food management
2. Use of drugs
3. Communication:
Physicians - Patients - parentsPhysicians - Patients - parents
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
bb
Intravenous“All”
Fasting
AntibioticAntidiarrhea
• ORT: ORS• Limited
IVbbFeeding:
Continue during & increase after diarrhea
Zn Suplementation
ANTIMICROBA
New formula ORS
ANTIDIARRHEA
Patient-Physician Communication
Incidence
& severitySelective
Past’70-’80
Present’80-now
Progress: management of diarrhea
ANTIMICROBA
ANTIDIARHEA
Duration, volume &IV
MostRecent
Patient safety+ Patient safety“No” P-D
communication
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Problems on diarrhea case Problems on diarrhea case managementmanagement
ORT:ORT:ORS fails to reduce stool volume & durationNot always available / acceptable
Not palatableToo costlyNot fulfilling energy requirement
NUTRITION :NUTRITION :Loss appetiteNutrient lost: vomit & stool lossesLoss of intestinal saccharidases
malabsorptionWithholding of foodCatabolic effect of the infection
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
THE INCREASE OF ORT USE FOR DIARRHEA 1991 - 2000
65
70
75
80
85
90
95
1991 1994 1997 2000
SOURCE : Indonesian Demographic Health Survey (IDHS)
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
1.NGO:Coord.Board of Ped Gastr
Community based program
2.Prof.Association
3.Universities
Research development
Curriculum innovation
THE ROLE OF INDONESIAN 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 : MEDIAC implementation to Medical Schools : 6 14 35 (all) Medical Schools Nursing Program
1996 : MED-IMCI
2000 :
DIARRHEA CASE MANAGEMENT
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
1994 1997 2000
Increased fluids: IDHS (2003) 56,5 57,0 96.7 * Urban 90,5 61,7 - Rural 53,5 56,5 -
Continued feeding: IDHS 52,0 49,6 -
Increased fluids and continued feeding: MCHS (2003) 31,9 Urban 27,3 Rural 36,0
MCHS : Mother & Child Health SurveyIDHS : Indonesian Demography & Health Survey
HOME MANAGEMENT OF DIARHEA
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Drugs given by HC personal in cases with bloody & watery stool
(1991-1992)
Drugs given by HC personal in cases with bloody & watery stool
(1991-1992)
Drugs given to 168 diarrhea attacks/ from 141 U5childen (out of 497 children living at 2 villages)
DysenteryDysentery WateryWatery
NN %% nn %%
Antibiotics & Antibiotics & antidiarrheaantidiarrhea
AntibioticsAntibiotics
Anti DiarrheaAnti Diarrhea
No drugsNo drugs
3
19
0
0
13.6
86.486.4
0
0
19
84
3
8
16.5
73.073.0
2.6
7.07.0
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Causative
agents
’78 – ’79%
(n:338)
’90 – ’92%
(n=131)
’04 – ’05% (n=638)
Enteropathogens
Rotavirus
ETEC (LT&ST)
Salmonella
Shigella
Cryptosporidium
E. Histolytic
Mix enteropahogens
56
38
11.5
6
4
0.3
7.6
80
66
NE
2.1*
1.8*
1.3**
0
3
29
Not yet analyzed
NE (not examined)
6
1
NE
NE
NE
Studies on the etiology of Diarrhea
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
2005 : Sardjito teaching hospital: ISO 20002006 : Study on “Patient safety study on diarrheal disease management”. 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.
Rotavirus and the Burden of Diarrhoeal Disease in IndonesiaCourtesy of U. Parashar
1 dot = 1000 deaths
GLOBAL DISTRIBUTION OF RV MORTALITYIN CHILDREN U 5
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
• 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 <5 yrs in developing countries
- U.S: $560 mill/yr, & $ 200 mill loss of productivity- PERU: $ 2.6 thsnds /yr- India:severe Diarrhea: $2,663/prson
median 440,000 death in <5yrs
RVWorldwide
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
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: ?
40
24.9
16
7.5 7.4
0
10
20
30
40
50
1972 1980 1986 1992 1996
Deaths: Diarrhea :2nd causeRV: ?
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1989 1990 1991 1992 1993 1996 2000 2003
Economic crisis
Mortality Morbidity
RVIndonesia
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
1970’s 1980’s 1990’s 2000’s
70 71 72
73 74 75
76 77 78
79
80 81 82
83 84 85
86 87 88
89
90 91 92
93 94 95
96 97 98
99
00 01 02
03 04 05
06 07 08
09
30 YEARS JOURNEY(UniMelb/RCH - GMU/ Sardjito)
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
1973 : Rotavirus discovery (R. Bishop, RCH/Unimelb) 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)1976 : Asymptomatic excretion of RV (RCH, Melbourne) 1978 : A case control hospital & a cohort
community design (GMU-RCH) published:
1979 : RV in Yogya, Indonesia – 38% of admissions – J Clin Microbiol
1973 : Rotavirus discovery (R. Bishop, RCH/Unimelb) 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)1976 : Asymptomatic excretion of RV (RCH, Melbourne) 1978 : A case control hospital & a cohort
community design (GMU-RCH) published:
1979 : RV in Yogya, Indonesia – 38% of admissions – J Clin Microbiol
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
1983 : Neonatal infection shown to protect against community strains (RCH, Melbourne)
1989 : Funding to prepare RV3 as an oral vaccine – Flow Labs, USA (RCH)
1994 : Phase I trial started – funded by AMRAD (RCH)
1997 : Phase II trial started – funded by AMRAD & Australian Government (RCH)
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
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 Atlanta. Funded by PATH (GMU)
2002 – 04 : An Extending Surveillance to Estimate the Disease Burden of Rotavirus
Gastroenteritis in Yogyakarta and Central Java Indonesia (GMU).
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).
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 Atlanta. Funded by PATH (GMU)
2002 – 04 : An Extending Surveillance to Estimate the Disease Burden of Rotavirus
Gastroenteritis in Yogyakarta and Central Java Indonesia (GMU).
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).
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Author Years/City Duration(mos)
Detection assay
Number Age (mos) % with rotavirus
Yati Soenarto(collaborator UniMelb)
1978-1979Yogyakarta
13 EM, IEM & Electrophoresis of Genome RNA
4230334
< 1< 11 mo 12 yrs
1.4037.8
Simanjuntak 1980-19811981-1982Jakarta
1212
ELISAELISA
466113
All agesAll ages
34.838.1
Sutoto 1980-1981Jakarta
13 ELISA 287 All ager 20.9
LONGITUDINAL RV STUDIES IN INDONESIA1978 - 2008
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Author Years/City Duration(mos)
Detection assay
Number Age (mos) % with rotavirus
Soeparto PWasito EB
198419961997
Surabaya
12601212
LXLXLX
113144319
0-240-240-24
31.334.536.142.0
Yati Soenartocollaborators CDC Atlanta, UniMelb)
2001 -2004Jogjakarta & Central Java
32 ELISA 1321 0-36 53.4
Yati Soenarto collaboratorUniMelb)
2005 – 2008Multicenter surveillance
On going ELISA 785 0-60 Not yet analyzed
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Study Characteristics Patient Characteristics
Authors Years/City
Duration/ months
DetectionAssay
Number Age (month)
% withRotavirus
Yuwono D 1990Bandung
5 RPHA 89*86**
0-36 40.9*24.3**
*: urban health center** : rural health center
A RV STUDY IN RURAL AND URBAN HEALTH
Study Characteristics Patient Characteristics
Author Years/City Duration/ months
Detection assay
Number Age (months)
Rotavirus seroprevalence
Sutoto ’80 – ‘81Jakarta
13 ELISA 136 All ages 16.2
A RV STUDY IN COMMUNITY
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
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
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
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
RV DISEASE BURDEN IN YOGYAKARTAAND 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%)
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
0
50
100
150
200
250
300
350
400
450
No Some Severe
Negative
Positive
Not Tested
No Yes
0
50
100
150
200
250
300
350
400
450
500
Rotavirus Negative
Rotavirus Positive
Dehydration
N valid = 1397
P=0.005
N valid = 1321
P=0.024
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Rotavirus by SeasonAugust 2001 - April 2004
02468
101214161820222426283032
nu
mb
er o
f ro
tavi
rus
det
ecti
on
0
10
20
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40
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60
RainfallE-RainTemperatureE-TemperatureRotavirus
Rainfall 5.3 3.2 6.8 6.7 5.2 17.116.35.3 4.0 3.2 4.8 7.7 1.5 4.8 1.5 8.7 7.7 5.6 16.67.5 1.5 4.2 4.8 8.4 1.5 4.8 1.5 9.5 9.7 10.85.5 8.6 0.6
E-Rain 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4 6.4
Temperature 25. 27. 27. 27. 26. 26. 26. 27.127.127. 26. 25. 25.126. 27. 27. 27. 26. 26. 27. 27. 27. 26. 24. 25. 25. 27.126. 27 28. 26. 26. 28.1
E-Temperature 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27 27
Rotavirus 55 36 12 7 13 23 31 23 29 12 21 47 45 37 18 10 7 11 13 13 18 25 39 43 36 18 5 8 5 1 7 16 21
A S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A
2001 2002 2003 2004
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Costs and Virus Types Mean Standard
Deviation
t-Test P-Values
Direct Medical Cost Expenditure
Rotavirus +
Rotavirus -
415
310
480.1
227.8
3.77 0.00
Direct Non Medical Cost Expenditure
Rotavirus +
Rotavirus -
101
84
133.2
122.1
1.77 0.08
Total Cost
Rotavirus +
Rotavirus -
517
394
512.6
275.4
3.99 0.00
Direct vs Indirect Cost
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
0.94.5
28.1
18.92
46.85
56.73
9.62
0
15.38
6.73
0
20
40
60
1978-1979 2001-2003
G1 G2 G3 G4 Non-typ.
G-type comparison: 1978-1979 and 2001-2003
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Rotavirus diarrhea: previous studies in Indonesia(53.4% vs 37.8%) Peak age: 12-24 months; Male > female (1.4:1) RV caused more dehydration significantly Obvious seasonal variation: highest RV during dry
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 78-79majority in 01-
03? Was non-type able In 78-79 G1? And Why?
SUMMARY (1)
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
1. 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 collected during that period of 1979-2001 is necessary.
What is next??
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
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
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
PalembangJakarta
Bandung
Yogyakarta
Denpasar
Mataram
Aceh Irian
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
INCIDENCE OF RV IN INDUSTRILIZED = IN DEVELOPING COUNTRIES IMPROVEMENT IN: WATER SUPPLY, HYGIENE & SANITATION: NOT ↓ RV DIARRHEA VACCINE IS NEEDED the 2nd breakthrough after ORT?Diarrheal Disease:•ORT reduced mortality•RV vaccine reduced morbidity
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
COLLABORATORS
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
• Partnership system• Priority research program• Specific projects
• Partnership system• Priority research program• Specific projects
Partnership & networking on research, Partnership & networking on research, education & clinical practice– could education & clinical practice– could
translational research being implemented?translational research being implemented?
Partnership & networking on research, Partnership & networking on research, education & clinical practice– could education & clinical practice– could
translational research being implemented?translational research being implemented?
COMMUNITIESCOMMUNITIES GOVERNMENTGOVERNMENT
UNIVERSITIESUNIVERSITIES
International collab.&
network PRODUCTS
IMPROVED HEALTH/QUALITY OF LIFEIMPROVED HEALTH/QUALITY OF LIFE
Career Career developmentdevelopment
linkageslinkages
inputinput Out putOut put
CAPACITIES
Diarrheal case management
Patient safety study on Diarrheal Disease
management
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
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 : NTB 193.759• The highest mortality : Sulsel 49??
(Subdit.Ditjen Diare P4D, 2005)
Rotavirus and the Burden of Diarrhoeal Disease in Indonesia
Terima Kasih