Sunday, 8 August 2010

Dengue Fever in Indonesia

Every year we are always surprised by the emergence of Dengue Hemorrhagic Fever (DHF), with a considerable number of cases. This resulted in a number of hospitals become overwhelmed in accepting the DHF patients. To overcome the hospitals to add beds in the halls of the hospital and recruit medical personnel and paramedics. The recurrence of dengue cases this causes a reaction from various circles. Some consider this to happen because of lack of public awareness of environmental cleanliness and partly because the government considers slow in anticipating and responding to this case.

In January to March 2004 total dengue cases in all provinces in Indonesia have reached 26.015, with as many as 389 people the number of deaths (CFR = 1.53%). Have the highest cases in Jakarta (11.534 persons) while the highest CFR is available at NTT (3.96%)
Dengue Fever or Dengue hemorrhagic fever (DHF) is a disease caused by dengue virus is transmitted through the bite of Aedes aegypti and Aedes albopictus. Both mosquito species have almost all corners of Indonesia, except in places a height of more than 1000 meters above sea level.

Aedes Aegypti Mosquito

Aedes Albopictus Mosquito

Dengue disease is often misdiagnosed with other diseases such as flu or typhoid. This is caused by a viral infection that causes dengue hemorrhagic fever may be asymptomatic or vague symptoms.  Data on the children showed RSCM DHF patients often show symptoms of cough, runny nose, vomiting, nausea, and diarrhea. Problems may be increased because the virus can go along with the infection of other diseases such as flu or typhoid. Therefore we need foresight of understanding about the course of the disease dengue virus infection, pathophysiology, clinical observations and sharpness. With a good clinical examination and complete diagnosis of DHF and investigation (laboratory) can be helpful especially when clinical symptoms are not appropriate.

DHF Patient
DHF was first discovered in Indonesia in Surabaya in 1968, but new virological confirmation was obtained in 1972. Since then the disease spread to many regions, so that until the year 1980 all the provinces in Indonesia except East Timor have contracted the disease. Since it was first discovered, the number of cases showed a tendency to increase both in number and total area affected and sporadic outbreaks always happen every year.
Largest DHF outbreak occurred in 1998, with the incidence rate (IR) = 35.19 per 100,000 population and CFR = 2%. In 1999 IR decreased sharply by 10.17%, but the subsequent years ie 15.99 IR tended to increase (year 2000); 21.66 (year 2001); 19.24 (year 2002) and 23.87 ( 2003).
 Dengue Fever in The World

Increased number of cases and the increase in the affected areas, due to the better transport of the population, the existence of new settlements, lack of community behavior toward cleaning mosquito breeding,  the presence of mosquito vectors in almost all corners of the country and the existence of four types of cells circulating virus throughout the year.
The health department has been working on strategies to cope with this case. At first the strategy used is to eradicate adult mosquitoes by fogging, and then expanded by using strategies that larvasida sown into water reservoirs that are difficult to clean. However both these methods until now have not shown satisfactory results.
Foging Strategi

1. Cause
DHF caused by dengue virus type DEN 1, DEN 2, DEN 3 and DEN 4. Viruses were included in group B Arthropod borne viruses (arboviruses). The four types of the virus have been found in various regions in Indonesia such as Jakarta and Yogyakarta. Viruses that grow in the community is a lot of dengue virus type one and three.

2. Symptom
Symptoms of dengue fever begins with:
a. A sudden high fever 2-7 days (38 C-40 C)
b. Bleeding manifestations, with forms: positive tourniquet test puspura hemorrhage, conjunctival, epitaksis, melena, etc..
c. Hepatomegaly (enlarged liver).
d. Shock, pulse pressure decreased to 20 mmHg or less, systolic blood pressure by 80 mmHg or lower.
e. Thrombocytopenia, at day 3-7 was found thrombocyte decline to 100,000 / mm.
f. Hemokonsentrasi, Hematocrit values increase.
g. Other clinical symptoms that may accompany: anorexia, weakness, nausea, vomiting, abdominal pain, diarrhea, cramps and headaches.
h. Bleeding at the nose and gums.
i. Pain in muscles and joints, red spots arise on the skin due to rupture of blood vessels.

3. Incubation Period
The incubation period occurred during 4-6 days.

4. Transmission
Dengue transmission occurs through the bite of the Aedes aegypti mosquito / Aedes albopictus females that previously have been carrying the virus in the body of another patient of dengue fever. Aedes aegypti originating from Brazil and Ethiopia and often bite humans in the morning and afternoon.

People who are at risk of dengue fever are children under the age of 15 years, and most live in moist environments, as well as rundown suburbs. Dengue disease often occurs in the tropics, and appeared in the rainy season. This virus probably emerged due to the influence of seasons / nature and human behavior.

5. Spread
Cases of this disease was first discovered in Manila, Philippines in 1953. Cases were first reported in Indonesia occurred in Surabaya and Jakarta, with total mortality by 24 people. Several years later the disease spread to several provinces in Indonesia, with the number of cases as follows:

- Year 1996: the number of cases of 45.548 people, with the number of deaths as many as 1234 people.
- Year 1998: the number of cases of 72.133 people, with the number of deaths as many as 1414 people (an explosion)
- Year 1999: the number of cases of 21.134 people.
- Year 2000: the number of cases of 33.443 people.
- Year 2001: the number of cases of 45 904 people
- Year 2002: the number of cases of 40 377 people.
- Year 2003: the number of cases of 50 131 people.
- Year 2004: March 5, 2004 till date the number of cases already reached 26.015 people, with the number of deaths as many as 389 people. 

Dengue prevention depends on a vector control, ie the mosquito Aedes aegypti. Mosquito control can be achieved by using some appropriate method, namely:
1. Environment
Environment for mosquito control methods such as by Mosquito Nest (PSN), solid waste management, modification of mosquito breeding places a byproduct of human activities, and improving home design. For example:
- Bathtub drain / water reservoir at least once a week.
- Changing / drain vase and place the bird drink once a week.
- Closes with water reservoirs.
- Burying tins, non used batteries and old tires used around the house and others.

2. Biological
Among other biological control using fish-eating
larva (fighting fish / fish Betta splendens), and bacteria (Bt.H-14).

3. Chemical
This control mode, among others:
- Fumigation / fogging (using malathion and fenthion), serve to reduce the possibility of transmission to a certain time limit.
- Provide abate powder (temephos) in places such as water reservoirs, water barrels, flower vases, ponds, and others.
The most effective way in preventing dengue is to combine the above methods, called the 3M Plus, the cover, drain, hoard. Also do some plus like larvae-eating fish, sow larvasida, use mosquito nets when sleeping, put a gauze, sprayed with insecticide, use a repellent, put on insect repellent, and check periodically pinched, etc. in accordance with local conditions.


Treatment of patients with Dengue Fever is a way:
Replacement of body fluids.
Patients were given a drink as much as 1.5 liters 2 liters in 24 hours (water tea or milk and sugar syrup).
Gastroenteritis oral solution / crystal that is salt electrolyte diarrhea (ORS), if necessary 1 tablespoon every 3-5 minutes.


In order to overcome the impact caused by the dengue fever disease, the Indonesian government has taken several policies, among which are:
a. Ordered all hospitals, either private or public to not refuse a patient suffering from dengue.
b. Request a director / president of the hospital to provide immediate relief to the DHF patients in accordance with applicable procedures and equipment as well as freeing the entire cost of treatment and care patients who can not afford appropriate PKPS-BBM / health card program. (SK Menkes No. 143/Menkes/II/2004 dated February 20, 2004).
c. Conducting mass fogging in areas affected by dengue lot.
d. Abate powder distributed for free at many of the areas affected by dengue. Conduct community mobilization to implement the eradication of mosquito breeding through 3M and recruit interpreters of mosquito monitoring.
e. Dissemination of pamphlets about the importance of air movement 3 M (drain, Close, Bury).
f. Lowering the technical assistance team to assist hospitals in the area, which consists of the following elements:
- Doctors Association of Indonesian Children
- Internal Medicine Specialist Doctors Association of Indonesia
- Regional Hospital Association
g. Assist provinces that experienced an outbreak with each fund of Rp. 500 million, beyond the free assistance to the hospital.
h. WHO consultant invited to give their views, suggestions and technical assistance.
i. Providing call center :
- DKI Jakarta, Pusadaldukes (021) 34835188 (24 hours)
- Department of Health, Sub-Directorate of Surveillance (021) 4265974, (021) 42802669
- Department of Health, Center for Health Problems (PPMK) (021) 5265043
j. Perform sero-epidemiological study to determine the spread of dengue virus.


In order to help overcome the disease dengue fever, Health Research and Development Agency has conducted several studies, among them:
1. Research Seroepidemiologi Dengue Virus Infection in Children and Adolescents in Mataram, 1998.
2. Research Evaluation and Development Working Group Particularly Mother Dasa Wisma DHF in the DHF Disease Transmission Control Implementation, Year 1999.
3. Research Improved Reduction of Dengue Haemorrhagic Fever (DHF) with Community-Based Approaches Community Health Education, Year 2000.
4. Development of Research Methods in the Eradication of Dengue Hemorrhagic Fever endemic area Grobogan district, Central Java, in 2001.
5. Unusual Research Dengue fever in Jakarta in 2003.
6. Outbreaks of Dengue Fever Research on Top Ten Hospitals in Jakarta in 2004.

Research and Development Agency in cooperation with Namru 2 surveilen has developed a system using information technology (Computerize) called the outbreak Early Warning Recognition System (EWORS). EWORS is an information network system that uses the internet which aims to deliver news of extraordinary events in a region all over Indonesia to the central EWORS (Research and Development Agency. Health Department.) quickly.
Through this system the increase and spread of cases can be detected quickly, so that disease control measures can be done as early as possible. The problem this time EWORS DHF has been instrumental in informing the data in terms of number of DHF cases, symptoms / disease characteristics, place / location, and time of occurrence of the entire second level hospitals in Indonesia.

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