Task-shifting.

 Task-shifting concept has been applied for many aspects in our life. It is not a new concept to be introduced in medical field but has been used for hundreds years. For the introduction, I would like to use one simple example in explaining about task-shifting. Basically, family consists of father, mother and children. Previously, the role of father is working to earn money or at least to get some food such as fish, chicken or rice, depending on the occupation. The role of mother is take care and looks after children for their needs as well as for her husband. These jobs include cooking and washing. Nowadays, women have dual functions. They do not only act as wife but do they have their own occupation outside their lovely home. The increase in workload has forced a lot of family to hire servant. This servant helps this family in term of cooking, washing, and look after children while parents working. The example mentioned above explained about task shifting.
 

     In relation to medical field, task-shifting is very important nowadays. Why it is important? This is because of the lack of human resource as a doctor. The world population is growing fast. The growing of population has expanded world population because the advance health care and technologies, we are able to increase life expectancy. This does not mean that the quality of life has been increased at maximum level. The increased in life expectancy has become other burden to health care facilities because of the increase in number of people with chronic diseases such as hypertension and cancer. At the same time, there is a serious shortage of medical doctor in many parts of the world. In Malawi for example, there is around one doctor for every 100 000 population.
 

      The phenomenon above has forced us to find other solution in providing adequate medical care to the patients as well as increase in accessibility of the patient to health care facilities and services. In Malawi for example, Government officials had determined a problem related to antiretroviral drugs prescription. This had led to change in the Nurses and Midwives Practice Act and Pharmacy, Medicines and Poisons Act that allow nurse to prescribe drugs for antiretroviral therapy. Other examples include the training of cadre. This task-shifting is not only occurs in low or middle income countries, but it also happen in developed countries. Sweden, United Kingdom and Canada have given authorities to nurse to prescribe medication.  Cadre is important because they can be accessed by population easily. Task-shifting from doctor to cadre could give some benefits if training is sufficient. If sufficient training of cadre is given, we can probably control factors that can lead to in-effectives and in-efficient care by cadres such as irrational drug use. The presence of cadres can be formal or informal. Ethiopia has established a new system related to new cadres creation known as Health extension Worker. The aim of this new system is to establish appropriate legal basis for new cadres so that it can be integrated into civil service system and the existing delivery and regulatory system.  

    In conclusion, task-shifting phenomenon must be evaluated carefully because it can either give a lot of benefits or simply reduce the effectiveness and efficiency of care delivery.

References:1. World Health Organization, 2008. Task Shifting, Global Recommendation and Guidelines.

SARS.

For this post, I would like to share with readers about SARS and coronavirus infections. Coronavirus is the virus that can cause Severe Acute Respiratory Syndrome. Basically, coronavirus can cause common cold (10 – 35%), with high prevalence of the disease in late fall, winter and early spring. SARS is an outbreak that occurred in 2002-2003. This new emerging disease is originated from Southern China that may be caused of human contact with infected animals such as palm civet, racoon dog or ferret badger. However, these animals are not the natural hosts for this virus. Horseshoe bat is thought to be the natural host.
Basically, the disease transmission can occur by several methods such as large and small aerosols as well as through fecal-oral pathway. Sneezing, coughing, and contact with secretes containing virus can lead to infection.
Pathogenesis of this virus begins with the attachment of virus to respiratory epithelial cells via angiotensin converting enzyme 2 receptor. The virus can disseminate systemically and can be found in blood, urine and stool (up to 2 months). It does not only cause serious lung infection but spread to other organs as well including liver.  In respiratory tracts, viral replication can lead to the damage of epithelial cells. Other than that, chemokines and interleukins are released as well in response to the damage. Other changes include hyaline membrane formation, desquamation of pneumocytes in alveolar spaces and infiltration of monocytes and lymphocytes. Virus usually persists in respiratory tract for about 2 – 3 weeks.

The incubation period of SARS is between 2 – 7 days in average. The clinical manifestation of SARS include high fever, followed by malaise, myalgia, and headache and followed by non productive cough after 1 – 2 days (first week). Some people develop diarrhea. In X-ray examination, we can see patchy consolidations that are frequently seen in lower lobes and peripheral lung regions or interstitial infiltrates. These can progress toward diffuse involvements. In second week, usually the conditions get worst with multi-organs involvement. Adult Respiratory Distress Syndrome may develop. Age more than 50, hepatitis, diabetes, and cardiovascular disease are the risk factors of developing severe form of disease.

The diagnosis of SARS can be confirmed by real time RT-PCR from respiratory tracts specimen and plasma early in the disease and from other specimen such as urine and stool after a week of the disease, tissue culture by using Vero E6 cells as well as serology test. In serology test, antibodies toward virus can be detected within 28 days after disease after the onset of illness. Other lab test that can be performed is blood test. In SARS, we can find lymphopenia with CD4 + T cells are the largest cells affected rather than CD8 + T cells and NK cells.  Thrombocytopenia can also be observed in as the disease progress.

The treatment include supportive treatment such as mechanical ventilator, IV infusion, immunomodulatory such as use of corticosteroid to prevent pulmonary fibrosis and other measures.

In conclusion, prevention of this emerging disease is simple. Hand washing and increased awareness of both infected person and community is needed to reduce the impact of epidemic or pandemic.

References:1. Fauci. Et al. Common Viral Respiratory Infections and Severe Acute Respiratory Syndrome (SARS). Harrison’s Principles of Internal Medicine. 2008.
 2. dr. Titik Nuryastuti Lecture Notes on The Emerging Disease Avian Influenza and Coronavirus/SARS. 2010.

Working together.

                                                                      (us.fotolia.com)

     In this post, I would like to give some information about working in a way that is effective and efficient. When we are talking about work, there are a lot of considerations need to be thought. Leadership and teamwork are two out of many aspects that are needed to produce excellent work. I will begin my explanation with leaderships. What is the meaning of leaderships actually? Basically, there are many definition related to this word. Leadership can be defined as a process of establishing direction for a group, gaining members’ commitments and motivating them to achieve goals. Other than that, Hemphills and Coons (1957), stated the meaning of leadership as the behaviour of an individual directing the activities of a group, towards a shared goals. Rauch and Behling (1984), gave other meaning but related; The process of influencing the activities of organized group towards goal achievements. The last but not least is the definition given by Jacobs and Jaques (1990), a process of giving purpose to collective effort and causing a willing effort to be expected to achieve purpose. Leader is a very important person in all organizations. Without leader, the goals or aim of a team or group cannot be formed and developed and the activities cannot be synchronized effectively. There are many characteristics of successful leader, and I would like to mention 9 traits of effective leader that are motivation, flexibility, intelligent, sensitivity to others, stability, self-confident, dominance, high energy and locus of control.
    In the first paragraph, I have mentioned some definition of leadership that consistently mentioned about group. What is group? Is there any different between group and team? A team is something more complex than group according to Weaver, 2008. Group is any collection of people that interacts each other because perceived themselves as having similar purposes or similar interests (Martin and Henderson, 2001). The names mentioned in previous sentence had added other elaboration about team; team is a group of with a sense of common goal or task, the pursuit of which requires collaboration and coordination of its members’ activities, who have regular and frequent interactions with one another. In order to clarify the difference between those terms, I will use one example. Let’s take Facebook as an example. There are thousands or perhaps millions of groups in this social networking program. If we join any group, we do not have any responsibility for that group. We can be either active participants or passive in which we do not do anything for contributing to that group but we join because we are interested in something and shared common interests with them. Team is different than this condition because as a part of team, you need to make decisions, take actions and agree with resolution which that would not have had to do as individuals. In a team, different organizations and professionals shared a common endeavour and act in different ways but expected to work efficiently together towards cooperation, collaboration and good coordination. One of the examples that can be mentioned here is rehabilitative team for disaster management. This team basically consists of 6 domains that have different educational and professional backgrounds but have the responsibility to work together, so that the goals can be achieved. This team consists of medical and paramedical staffs, local authorities, orthotists and prosthetists, NGOs, relatives and neighbours as well as the patients themselves.
    In conclusion, teamwork is a very important concept to be understood. So, everyone in the team knows about their specific roles and responsibilities. Together with the leadership concept, it would produce more efficient and more effective coordination and collaboration.

References:
1.Rai, F. 2009. Leadership and Motivation among Health Care Staff.  (online accessed on December 4th   2010)
URL: http://www.gfmer.ch/GFMER_members/pdf/Leadership_motivation_Fuad_Rai_2009.pdf
2. Tzenalis, A. Sotiriadou, C. 2010. Health Promotion as Multi-professional and Multi-disciplinary Work. (online accessed on December 4th   2010)
URL: http://www.caringsciences.org/volume003/issue2/Vol3_Issue2_01_Tzenalis.pdf

Driving Force

(deddyanwari.com)

   What is the meaning of motivation? When we see other people are very dedicated of doing something, can we say that they are motivated? Or in case of someone need to do something because he or she is forced to do it, can it be considered as motivation? In this post, I will focus more on the motivation and share some theories and perhaps an example regarding this topic. According to Higgin, 1994, Motivation is related the internal force that drive person to satisfy the unsatisfied goal. In this context, a person is forced to be dedicated or diligent to her or his work. Moreover, motivation is important of the good outcome because person with higher motivation level will do work optimally in order to achieved the desired goal. Other definition of motivation was formulated is a ration of how well an organization converts input in the form of resources, labour, materials, machinery into goods and services (Sink, 1984).
    Motivation is very important in all aspects of life. Because of our future career is medical doctors, I would like to focus more on the health care setting. Basically, motivation of health care workers are related to many aspects such as good incentives, supportive environment, good communication, well-structured organization and many other factors. Lack of motivation can decrease the performance of the work. Commitment toward something is also related to motivation. Lack of motivation can lead to lack of commitment as well. As a result, it can lead to high turnover rates and poor morale. High turnover rates can threaten health care organization in term of profitability, quality of care as well as the fiscal viability of the organization. Why this consequence can occur? Basically, replacement costs more than retention of the worker. According to Joint Commission of Accreditation of Healthcare Organization (JCAHO), in order to replace a nurse, 100% of nurse salary needs to be spent. Example of the turnover case that can increase the hospital cost in replacement is:
       Let say the turnover rates of 30%, the current average turnover rate among health workers and hospital employing 1000 nurses at $ 50 000 per nurse per year will spend $ 15,000,000 a year in replacement cost.
      The cost of when nurses are retained is more cost effective because we can allocate organization fund to give more incentives in term of bonus to the health workers who perform their job well. Other external motivation measures that can be used to sustain healthcare worker are free parking area for worker and contests. Free parking area for worker may lessen our financial burden especially for worker that has low salary. Seminar and program such as short course training can also be done to improve the quality of care by health care workers. Even though incentive and other measures mentioned above are related to increase in commitment and retention, the effect is short. Other measures such as providing the corporate culture that remove the barriers or increases the employee’s potential to find meaning of work should be implemented for long term effect results.
   In conclusion, motivation is an important aspect to drive individual and organization to be dedicated to achieve their aims or goals optimally.

References:
1. A.O. Okaro. Et al. 2010. Impact of Motivation on Productivity of Radiographers in TwoTertiary Healthcare Institutions in Enugu Metropolis Southeastern Nigeria. (online accessed on December 2nd 2010)
URL: http://www.eurojournals.com/ajsr_8_04.pdf
2. Morrison, Eileen E.; Burke, George C. III; and Greene, Lloyd, "Meaning in Motivation: Does Your Organization Need an Inner Life?"(2007). Faculty Publications-School of Health Administration. Paper 1. (online accessed on December 2nd 2010)
URL: http://ecommons.txstate.edu/cgi/viewcontent.cgi?article=1000&context=sohafacp

First step to come.....

                                                                (topbillinmusic.com)

 Travel Medicine is one of the fields in medicine that concerns about many aspects of diseases related to travel. It involves interdisciplinary health specialties such as epidemiology, preventive medicine, emergency medicine, infectious diseases, tropical diseases, gastroenterology, dermatology and others in its application.  As we know, different parts of the world have different disease distribution. There are many risks that should be evaluated before we can go to other countries such as destination itself.
    Basically, there are many preparation need to be done before we travel to the other countries. One of the preparations is pre travel medical recommendations:
1. Consult your physician, local Public Health Department, or travel clinics before you are travelling ideally 4-6 weeks before you travel. This allows us to be immunized or taken chemoprophylaxis for malaria as needed.
2. Prepare a traveller’s health history and traveller medical kit. Traveller’s health history consists of several information such as recent medical condition, recent drugs use (generic and brand name as well as the dose), history of drugs allergy, ABO blood type and rhesus factor type, up to date immunizations, name and telephone numbers of your physician as well as the closest relatives.
3.   Make sure you bring your hand phone that in which you can make international call in emergency case.
4. Make sure you have your physician numbers –office, mobile phone as well as fax.
5. Check your insurance coverage for accidents and illness occurring outside your home country.
6. Specifically inquire if your regular insurance policy or health policy will cover medical evacuation by air ambulance.
7. Arrange additional medical plan if you do not have it in case of emergency situation.

   Immunization and chemoprophylaxis plan should be consulted with your physician and we can also check the other websites that provide up to date information regarding disease outbreak, endemic, epidemic and pandemic such as World Health Organization (WHO), Centre of Disease Control and Prevention (CDC), as well as other public and private organizations. In malaria endemic area such as Africa, chemoprophylaxis should be taken against P.falciparum that is resistance chloroquine should be prescribed with doxycycline and atovaquone/ proguanil. Other areas in which hepatitis A is common vaccine should be given. This vaccine should be given and can confer immunity for a year. Second vaccination with hepatitis A after 6-12 months will confer immunity for about 20 years. Typhoid vaccination will confer immunity up to 3 years. Hepatitis B vaccination should be given to people who are planning to work as healthcare workers overseas in which hepatitis B is common there. Other groups include tourist who would like to stay for long periods (more than 3 months). Cholera vaccination should be given to those backpackers travelling to remote area with limited access to medical care as well as people who are working as volunteer in refugees camps and in disaster relief.
    
   In conclusion, prevention should be taken early because this can prevent transmission of the disease from the other countries as well as bringing infection to our own countries. Travel medical triad that consists of the traveller, the trip and the proposed health intervention.

References:
1. Jong, E.C.Approach to Travel Medicine and a Personal Travel Medicine Kit. (online accessed on December 2nd  2010)
URL: http://www.thelancetglobalhealthnetwork.com/wp-content/uploads/2008/03/jong_ch01-x2613.pdf

2. NHS, 2009. Travel Medicine Guidelines. (online accessed on December 2nd 2010)
URL:http://www.brightonandhovepct.nhs.uk/healthprofessionals/clinical-areas/prescribing/guidelines/documents/TravelmedicineguidelinesNovember2009Updated.pdf

Rabies

(websters-online-dictionary.org)

  Rabies is one of the viral diseases that infect Central nervous system. For this topic, I would explain more about medical aspect of rabies. Rabies virus belongs to rhabdoviridae family. This virus has become one of diseases that need serious attention because of its clinical manifestation that at worst can lead to death. Early prevention is necessary to prevent complications. Rabies was previously thought to have dogs as its primary hosts and vector. Surveillance and vaccination programs carried out in North America and Europe have revealed wild animals such as bats, racoon and foxes as major hosts for rabies. Basically, different animals have different specific variant or variants. Different variants in different hosts are distributed in different areas geographically. Bats have unrestricted distribution and seemed to be the major contributor for rabies infections in human. This mammalian has one specific variant known as Ln/Ps that has the ability to bind to certain cell receptors or have the greater efficiency in initial replication in non neuronal tissues. Other than rabid animal bites, other means of transmission of rabies are infected corneal transplantation, infected solid organ transplantation, exposure of mucosa or un-intact skin to saliva of rabid animal and etc.

     The pathogenesis of this virus is related to its ability to bind to nicotinic receptors. Before I explain further about the pathogenesis, I would like to give some information about the incubation period. The incubation period for rabies infection is between one month and three months. In rare cases, as short as 2 weeks or as long as more than a year incubation period can occur. Before the virus bind to nerve cells, the replication occurs in other cells, predominantly in muscle cells near the inoculation sites. The presents of specific receptors allow the invasion of both sensory and motor neurons. The transportation methods used are fast axonal transport of virus heading towards spinal cord and brainstem. Virus spread to gray matter in CNS via neuroanatomic connections and leads to inflammatory changes mostly and neuronal death in few neurons. This condition leads to neuronal dysfunction that produce rabies symptoms such as encephalitis, flaccid paralysis and other serious manifestations such coma and death.

       There are three phases of rabies disease: prodrome phase, acute neurologic phase and coma/death phase. The duration of each phase varies.  The duration of prodrome phase is between 1 -7 days. The symptoms include fever, malaise, nausea, vomiting, anxiety, agitation, pruiritus, pain and paraesthesia at the site of inoculation and headache. In acute neurologic phases, there are two kinds of manifestations: encephalitic (in 80%) and Paralytic (in 20%). The duration for the former is 1- 7 days and the latter is 2-10 days. The symptoms of the former one are fever, confusions, hallucinations, hyperactivity and pharyngeal spasm that can lead to hydrophobia as well as seizures. In paralytic rabies the symptom is ascending flaccid paralysis. The third phase duration is 1-14 days.

   In conclusion, rabies can be prevented from complication development if early intervention by rabies PEP is carried out. The awareness of the population in which the prevalence of rabies are high should be raised through education and campaign measures for examples. The information above is simplified and further information can be obtained from Harrison book. 

Reference:

1.Fauci. et al. Rabies. Harrison's Principles of Internal Medicine. 2008.

What's bothering them?

(debateitout.com)

    In this post, I would like to explain more about post-traumatic trauma disorder (PTSD). If stress is present in acute state and is not recurrent, it may have low probability of developing PTSD. PTSD is common in many unresolved case. The incidence of PTSD is higher when mass disaster happened such as Jogjakarta Earthquake in 2006. There are many clinical manifestation of PTSD including associated symptoms of detachment and loss of emotional responsivity, avoidance behaviours toward stimuli, recurrence thought, dreams and flashback of the events as well as feeling of depersonalized and unable to recall the specific aspect of trauma.

Moreover, there are three stages of disaster’s victim psychological reaction: Shocked stage, Honeymoon stage, Disillusionized  stage. The first stage usually occurs just after the event hit until several days of disaster. There are many criteria of victim who are still living in this stage such acquiring basic needs to survive, finding a place that is secure – that can provide adequate food, and place for sleep, having unclear recognition of reality such as still go to the office to work despite of having serious disaster, concern about their family members excessively and many other symptoms. In the second stage, the duration may vary from each individual. It can take several weeks or several months to proceed to the third stage. People reactions in this honeymoon stage may react differently. Some people tried to escape from the disaster area and migrate to the other area that is more secure. For some people who have skills or other abilities to survive in the new place, this action may allow them to recover faster than other people in term of economy. Other than that, some response by staying at their home instead of dangerous condition that threats them. The action taken may be due to their concern about home or attachment to their home. In this stage, many people are expected to have sleepiness. The third stage is the disillusionized stage. In this stage, people stage to feel hopelessness when mass media stop the reporting the disaster and people that are not affected by disaster (who are living outside the area) start to forget about them. This stage may occur after several months of honeymoon stage and may last for more than a year. 

  The etiology and pathophysiology of PTSD are related to the excessive norepinephrine discharge in locus coeruleus as well as increase in noradrenergic discharge at projection sites in hippocampus and amygdala. This theory correlate PTSD and fear-based memories.

  The treatments of choice for PTSD are SSRIs, TCAs such as imipramine and amitriptyline, MAOI phenelzine, trazadone (for insomnia treatment), propranolol (used in acute phase for PTSD prevention), and many other medications. The first three groups of drugs mentioned above help in reducing anxiety, symptoms of intrusions and avoidance behaviour. Psychotherapeutic therapy can help in the treatment of avoidance therapy and demoralization. 

References:1. Fauci. Et al. Stress Disorder. Harrison’s Principles of Internal Medicine. 2008.
2. Sakurai, S. Miyata, S. Nakagawa, I. PTSD and Natural Disaster.
. [online accessed on November 29th 2010]
URL: http://www.soi.asia/seminar/tsunami/material/PTSD_miyata.pdf

Me First please.....

                                                                 ( mysafety1st.com)
                           

   Triage is the concept that is introduced by Napoleon’s battlefield surgeon. The concept stress on the need for us to treat the most seriously injured to receive the care first. This concept is usually needed in the case of mass disaster. Disaster mentioned here can be natural disaster such as cyclones or manmade disaster such as bombing. In mass disaster, the resources available to provide greatest conventional care for each individual injured usually are not sufficient. So, patient that seriously needs the care must be treated first in order to increase the chance of survival.

   Basically, triage can be divided into five categories: Immediate, delayed, minimal (walking wounded), expectant and dead. In the initial phases, only two phases are considered important: immediate or non-immediate. Immediate category . Later, more categories can be defined when the casualties influx subsides and nature and extend of injuries and resources are known, and more evaluation are carried out.

   Patients who are classified into immediate category must be treated first because they are having life-threatening case. There are many examples of life-threatening case such as open chest wound, tension pneumothorax, airway compromise, unconsciousness with focal signs, hypotension, active external haemorrhage and intermediate burn. These conditions can be treated by simple intervention such as rapid external wound compression, laparotomy for splenectomy, endotracheal intubation, tube thoracostomy that would stabilize patient immediately after the intervention. These interventions are not only life saving but can also give more space for other patients that are belong to the same category to be treated as soon as possible. 

        Other category is delayed. Patients with extremity vascular compromise, spinal fractures with or without spinal cord injury, pelvic fractures, open or closed extremity fractures, penetrating torso fractures, soft tissue wounds, unconsciousness without airway compromise or lateralizing signs and etc are classified into this group. Continuous monitoring is needed and intervention such as IV infusion, volume repletion, administration of analgesics and antibiotics, covering open wounds are immobilizing fractures can reduce the morbidity. These interventions are included in minimal acceptable care. Patients must be placed in the area in which the immediate patients group are placed to avoid crowding and confusion.

     The minimal group is the one who always arrive at the hospital early because of their ability to walk using their own power. Patients in this group are usually do not need intensive treatment but may require first aid treatment. Medical team must monitor these patients for any deteriorating conditions.

    Expectant is related to the patients with the conditions that are serious with low chances of survival but are still alive. This condition may confuse us from giving the right treatment to the patient classified into immediate group that are more beneficial. The examples of conditions that classified into expectant condition are serious head injuries with open skull fractures or unconsciousness, extensive and deep burns and imminent cardiac arrect with major torso trauma. They basically need to be monitored for any improvement that may warrant care as well as kept comfortable.

  The last but not least is the dead category that is important to be differentiated from other group to prevent unnecessary resuscitation and intervention. Moreover, the process will make later processes of identification as well as communication to the family of the dead person easier.

References:
1. E.R. Frykberg. Triage: Principles and Practice. 2005.   [online accessed on November 28rd
 2010]
URL: http://www.fimnet.fi/sjs/articles/SJS42005-272.pdf

I need your help!!!!

 

   Identification of the dead body is very important before we can release the body to the family. Forensic medicine is a branch in medicine that help in identification of the dead body as well as the cause and manner of death, the date and location and other information that cannot be obtained from ante mortem sources. In this topic, I would focus on the forensic odontology in identification of the dead body. As we know that the dead body cannot speak and tell us what was going on them before the death and has been waiting for us to investigate the case related to them, so that, we can produce sufficient evident to fight for them in criminal case. Why dental odontology one of the important branch? According to my lecturer, dr. Yudha, fingerprint, dental profile and DNA can be used as primary evidence whilst secondary evidences that can be used include visual, photography, properties and medic-anthropology data. Why teeth can provide a very useful information? This is because teeth are the hardest part in our body – the enamel. In many cases, teeth remain intact. The data can be collected from ante mortem as well as post mortem basis. As we know, we two phase in teeth development. The second phase is the development of permanent teeth that is usually develops in the first decade. Human basically can have up to 32 permanent teeth with 5 surfaces each. The surfaces can be either filled with restorative materials or not. Basically, people around the world do have visit to dentist at least once in their lifetime. The purpose of visiting varies such as just for routine check up, treatments or check for disorders. This may give the opportunity to dentist to develop a record of the patient regarding their teeth characteristics during life. Other than that, other data such as radiograph, study models and dental photographs can provide better ante mortem data to the forensic team. The effectiveness of the ante mortem data relies on many factors such as accuracy of the record and the storage of the data. In some places, data that are stored in the form of paper maybe destroyed by certain situation such as tsunami. But what happened when ante mortem data is not available even though we know that it has large contribution to the identification together with post mortem data? In this case, post mortem data alone can also contribute something such as the age of the person at time of death, socio-economic status, unusual oral habit and type of diets. 

 

 

In mass disaster, there are usually many dead bodies presented at time. If only 12 bodies, it may be possible to use other method as combination. If the dead bodies are too many such as in the case of tsunami, what can we do to perform quick identification? Forensic odontology is the answer because it is simple and inexpensive method. Compared with DNA method, DNA method is very expensive, need sophisticated technology as well as need longer time. Moreover, the infrastructures as well as transportations are damaged during disaster, making the process of identification more difficult. For further info, it may be useful to refer to my previous post: unpredictable situation.

How about birthmark analysis? What is the use of this? Basically, it can be used in crime scene investigation. It is can be used to differentiate whether the purpose of the perpetrator are sexual, child abuse or other assaults forms.

In conclusion, forensic odontology is a useful method in many cases such as mass disaster, domestic violence and child abuse. More specialist is need because we are now facing unpredictable natural and manmade disaster that cause mass disaster.

References:
1. Amad, H.S. Forensic Odontology. [online accessed on November 26th 2010]
URL: http://www.smile-mag.com/art_files/Forensic_Odontology.pdf
2. Stavrianos, C. Et al. Application on Forensic Dentistry: Part 1. [online accessed on November 26th 2010]
URL: http://docsdrive.com/pdfs/medwelljournals/rjmsci/2010/179-186.pdf

Long term commitment.

                                                                   (pointblank-dm.com)

        The title above is related to chronic disease management. For this topic, I would explain how we can improve chronic disease management at different levels in our health system. This topic is important because chronic diseases such as heart disease, diabetes mellitus or stroke have been increasing in low, middle and high income countries. People now are living longer even though they are having disease that cannot be cured. This phenomenon occurs due to the advance in health care and technology. Before we go into details related to chronic disease management, I would like to give some definitions. According to WHO, chronic disease is the diseases of long duration and generally has slow progression. CDC has different version of definition. According to CDC, chronic disease is a disease that cannot be cured once acquired. Other than that, criteria of having the condition for three months or longer are included in this definition. There are many risks of developing chronic diseases such as physical inactivity, unhealthy diet and tobacco use that are modifiable and age and hereditary factors that are non-modifiable.

Management.
Chronic disease management is defined as systematic approach to coordinating health care intervention across the levels (individual, organizational, local and national). Three main levels underpinning by population-wide disease prevention and health promotion are formulated from Kaiser Permanente care triangle. These include the self supporting care, disease management and case management. The management as mentioned above focus on three levels.

      The first level is the individual levels. There are many approaches that can be used at this level such as psychological and behavioural theory, stages of change model and some of the case managements. Stage of changes is one of the effective methods used and originated from the intervention of smoking cessation as well as alcohol and drug addiction. There are five levels in this approach including pre-contemplation, contemplation, decision, action and maintenance. These processes can take place in many setting such as in the hospital. Other than that, telephone can also be used as one of the individual proactive support. This is proven by United States. Even though some approaches seem to be simple, but that does not mean that they are easy to be carried out. A lot of considerations such as the affordability of individual, the availability of the technology, the accessibility of population, cultural view and etc should be taken into account. Moreover, we can take one of the examples in stage of changes that involved nurses as care managers, physician and specialist working together. This study was carried out in the one of the region in Italy. This study used team-based model and stage of change.  The stage of change was carried out by nurses who supported patient with regular motivation and reminders, acts as signposting service to other resources and coordinate care for individual at general practices. This intervention used face-to-face approaches rather than telephone.

 

                                                                          (fachc.org)

      The second level is the delivery-level initiative. The concept of generic chronic care model originated from US is now being adapted to Europe countries. This concept consists of six interdependence components that are important in chronic care management: health care organization, decision support system, self management support, clinical information system design and resources and policies. Some governments have provided incentives for improving the health care management in chronic disease case as well as new risk adjustment mechanism.

The third level is the system wide initiatives. There are many countries implementing service delivery policies even though they aspire to system wide approach. In order to carry out this approach, we need to understand about the scope of this level. Basically, it is similar to the second level but the focus is different. System-wide level focus on the policies, structures and community wide resources needed for the implementation of long term changes. WHO’s innovative care for Chronic Conditions Framework, focuses more on the policies and community aspect. Furthermore, other system wide policy approaches are the ecological or public health model for chronic diseases. Population wide policies, community activities and health services are important as principles. 

In conclusion, in order to make the chronic disease management to be effective, we need to learn from the other countries. Even though, Indonesia is one of developing countries, early policies approach can lead to a better management in chronic disease. As I mentioned above, the other considerations such as cultural and accessibility factors, needs to be taken into account when formulating and stipulating the new policy. 

Reference:
1. Singh, D. How can chronic disease management programmes operate across care settings and providers. WHO Regional Office for Europe and European Observatory on Health System and Policies. 2008. 

Cycle ......

       Disaster is a condition that needs external resources to cope with the impact of the hazards occurs in an area. For this post, I would explain more about disaster but I will focus more on the disaster management cycles. Other than that, I would also describe some information related to two countries, Malaysia and Indonesia in the management of disaster in both countries. Before we proceed further, it is good for us to know the definition of the disaster management. Disaster management is the sum total of all activities, programmes and measures that are carried out before, during and after disaster in order to avoid a disaster, reduce its impact or recover from its losses. I believe that for each country in the world, the management of disaster is one of the important elements to be taken into account in government. Malaysia has its own organization that is responsible for the management of the disaster. This organization is known as Malaysian Centre for Remote Sensing (MACRES). Indonesia with ten times number of citizens in the country compared with Malaysia formulated three levels organizations for its country. These include BAKORNAS PB, SATKORLAK PB and SATLAK PB. I would explain more later in this chapter.

   Basically, for each disaster, there is one cycle that consists of three stages that need different kind of management. The first stage is pre-disaster stage. In this stage, a lot of measures can be taken in order to reduce human and properties losses such as carry out campaign to increase the awareness of population regarding the hazards, strengthening the existing weak structures and preparation of disaster management at individuals and community levels. Two important activities are always taken into consideration in this stage that is preparedness and mitigation. The former concerns about the rapid response of government, community and individual to disaster situation. Some of the examples related to preparedness are formulation of viable emergency system, the development of the warning system and maintenance of inventories and the trained personnel. The latter is related to the intervention for the reduction of the impact of hazards and the vulnerability. In order to perform this, we can either focus on hazards or the elements that are vulnerable to threats. Some interventions such as the storage of the water in drought prone area and relocating people living in hazards prone area to the temporary centre when the risk to be affected increased can be done. Malaysia under MACRES has established MACRES Ground Receiving Station in Temerloh, Pahang, that are able to receive downlink from SPOT-2, 4, 5, RADARSAT, NOAA, MODIS, and OCM. The role of MACRES is to disseminate info, provide early warning as well as establish disaster management system.

   Second stage is the stage of during disaster and the organizations in charge must make sure that the people needs and provisions are met and the suffering is minimized. It can take place at many locations such as damaged area, pre hospital area as well as hospital area. In pre-hospital setting, several measures can be carried out such as triage, resuscitation, stabilization, and transportation. 

 

   The third stage involves the response and recovery activities to achieve early recovery and rehabilitation of the community. As I mentioned above, Indonesia has its own mechanism in handling disaster through three main organizations. The first one is BAKORNAS PB that is chaired by Vice President and is a national coordinating board for disaster management. The functions of BAKORNAS PB are as policy makers, coordinate the implementation and monitoring the activities in disaster management, as well as rendering guidelines and direction for disaster management. SATKORLAK PB is a provincial coordinating unit for disaster management and SATLAK PB work as a implementation unit at districts or municipals level. The former is chaired by Governor and the later is chaired by Bupati or Mayor of the city. Indonesia has been using satellite as well for the management of disaster.

      In conclusion, even though each country has its own hazards but the management are slightly similar that focus on the immediate action taken in order to reduce the impact and increase the pace of recovery process. Learning form experiences and other countries can be used as one of the methods for the improvement of quality, effectiveness and efficiency of disaster management.

References:

1. Vihar, P. Delhi, 2006.  Natural Hazards and Disaster Management. Introduction to disaster management. Disaster management cycles.

2. BAKORNAS PB.  [online accessed on November 23rd 2010]

URL: http://www.aprsaf.org/data/aprsaf13_data/2_1_INDONESIA DM_1515day1.pdf

3. Hashim, M. National Disaster and Remote Sensing in Malaysia. [online accessed on November 23rd
 2010]

URL: www.aprsaf.org/data/jptm2_pdf/JPTM200606_12.pdf

4. Hendro Wartatmo. Medical Emergency Response.

Unpredictable Situation

                                                                     (booklyn.org) 
 Disaster as I mentioned and explained in previous post is something that cannot be predicted in some cases. This is true for the tsunami that hit Thailand in December 26, 2004. No one expected that earthquake with 9.0 Richter scale in Aceh would result in an estimated 5,395 death 8,500 injured people in Thailand. In my discussion below, I would emphasize more on the forensic management in Thailand specifically and not related to other countries affected by this mass disaster. Before we go further, I would like to give definition of mass disaster. Mass disaster is the disaster that killed 12 or more people in a single event.

In mass disaster, forensic team plays a very important role in the management of dead body. In Thailand’s tsunami situation, only the identification of the dead body was focussed instead of general purpose of forensic investigation that include the identification of the victim, the time and location, cause and the manner of death.

Basically, dead bodies scattered in tsunami affected area must be recovered soon before it undergo decomposition. Decomposition would make the forensic identification become more difficult. According to my lecturer, Dr. Yudha, there can be primary such as dental or secondary methods for identification. In this case, there were four major identification methods used that are dental (85.5%), fingerprints (12.6%), DNA (0.4%) and physical (1.2%). The physical method is less accurate when the duration taken for investigation was prolonged because of decomposition and the refrigerator available for dead body storage was not sufficient. This is different for Thai citizen. For Thai citizen, dental method contributed about 55% for the investigation, whilst fingerprints contributed around 39% but was getting increased due to the increased in ante mortem fingerprints data from family members of the victims. The DNA method used DNA sample from buccal mucosa, hair, and muscle tissues before decomposition but after that period the sample taken from tooth, femur and rib were more useful.

The dead bodies in this disaster were managed by some organizations as mentioned below:
a. Department of Disaster Prevention and Mitigation of Ministry of Interior.
b. Royal Thai Police.
c. Forensic science Institute, Ministry of Justice.
d. Universities.
e. Military.
f. Local Government.
- Helped in identification and released of the bodies to the family members of the victims.
g. Public health personnel.
- provide additional equipments and supplies.
h. Non-government organizations.
i. Ministry of Public Health
- provide the equipments and supplies
j. Other volunteers.
- Helped in transferring the bodies, numbering and tagging, cleaning of the bodies.


Even though these elements collaborated each other but the Department of Disaster Prevention and Mitigation of Ministry of Interior had taken the responsibility and provided the guidelines for dead body management and ordered the Royal Thai Police to consolidate the identification. TTVI that stand for Thai Tsunami Victim Identification was established later when the Royal Thai government realized the bodies were getting more decomposed. This situation need more experienced expert in handling this. So TTVI was the solution formed under Thai authority that allowed international collaboration to provide equitable treatment of the bodies.

In conclusion, the management of the mass disaster like tsunami really need proper guidelines and immediate action taken in order to make it cost-effective and increase the pace of the management.

References:
1. Sribanditmongkol, P. Et al. Forensic aspect of disaster casualty management
Tsunami Victim Identification in Thailand [online accessed on November 22th 2010]

URL: http://www.who.int/hac/events/tsunamiconf/presentations/2_16_forensic_pongruk_doc.pdf

Disaster?

This post is related to one of my block topics and to our latest disaster that hit my second home, Yogyakarta that started on 26th of October, 2010 and peaked on 5th of November, 2010. In this post, I would like to give a piece of information that hopefully, will help us understand about the concept of disaster.

Disaster? What is the meaning of disaster actually? If earthquake occur in the island in which there is no people and does not radiate (in term of vibration) to the other uninhabited area, it is considered disaster? Disaster word is originated from old French word, disastre. This word is a combination from the word Dis (bad or evil) and the word aster (star). The meaning of disaster is “A serious disruption in the functioning of the community or a society causing wide spread material, economic, social or environmental losses which exceed the ability of the affected society to cope using its own resources”.

There are four elements to be mentioned here; hazard, risk, capacity and vulnerability.

The hazards
Hazard is a dangerous condition or event, that threat or has potential of causing injury to life or damage to property or the environment. Hazard can be divided into natural, manmade or combination of both. The natural hazards such as earthquake or volcano eruption occur because of natural phenomenon. The manmade hazards such as wars, civil strikes or pollutions occur due to human negligence. Floods occur due to combination of both. We can take Merapi eruption as an example. If the human does not manage the path of the lava properly, it can lead to flood.

The Vulnerability
Vulnerability is the Extends to which a community, structure, service, or geographic area is likely to be damaged or disrupted by the impact of particular hazards, on account of their nature, construction and proximity to hazardous terrains or a disaster prone area.

Two categories of vulnerability; physical and socio-economic. The physical vulnerability is the related to “who” or “what” questions in term people or things that may be destroyed or damaged by natural disaster. Socio-economic vulnerability is related to the degree to which the population is affected by hazards not only in term of physical but socio-economic status as well. There were many people that were evacuated during Merapi eruption 2010, have been living in depressed state because they are not really strong in term of economy. Most of them who were living nearby Merapi volcano lost their properties such as house and their crops and poultry to which they depend on.

The capacity:
Capacity can be defined as “resources, means and strengths which exist in households and communities and which enable them to cope with, withstand, prepare for, prevent, mitigate or quickly recover from a disaster”.

Capacity can also be divided into two:
a. Physical.
b. socio-economic.

The physical capacity is related to human power to save things from their destroyed houses or from their farms and their ability to live in other area due to the skills or ability they posses to survive.

The socio-economic status is related to recover from disaster. Poor people suffer the most in most of the cases.

The risk:
Risk is a “measure of the expected losses due to a hazard event occurring in a given area over a specific time period.  The level of risk depends on three elements; nature of the hazards, vulnerability of the elements which are affected, and economic value of those elements.

References:
1. Vihar, P. Delhi, 2006.  Natural Hazards and Disaster Management. Introduction to disaster management.
[online accessed on November 19th  2010]

URL:
www.cbse.nic.in/natural%20hazards%20&%20disaster%20management.pdf

Incurable Disease

HIV/AIDS has become one of the major problems globally for decades. This problem does not only affect the health of carrier in poor and developing countries, but also affect people in developed countries. Once infected, there is no other way to reverse the condition. So, it is important for us to take some massive measures to prevent the spread of the disease in the population.

A piece of information about HIV/AIDS ....

History.

The reveal of AIDS was first recognized in summer 1981 when five previously healthy homosexual men with Pneumocystis jiroveci pneumonia in Los Angeles and 26 previously healthy homosexual men with Kaposi’s sarcoma with or without P. Jiroveci in Los Angeles and New York were detected. These cases were followed by the detection in female and male injected drugs users, in blood transfusion recipients, and in haemophiliacs.


Group at Risk (High):

 1. Injected Drug Users.

2. Heterosexual contact.

3. Male-to-male sexual contact.

My focus on this topic:

Circumcision is thought to reduce the risk of HIV transmission from women to circumcised men. This fact is supported by three randomized controlled trials that were carried out to examine the impact of male circumcision on HIV transmission. Three countries were involved in this studies; South Africa, Uganda and Kenya. In Orange Farm, South Africa, 3274 uncircumcised, HIV-negative men, aged between 18-24 years old were enrolled. The result showed 61% protective effect against HIV acquisition (Auvert et al., 2005). In Kisumu, Kenya and Rakai District, Uganda, 2784 and 4996 HIV-negative candidates respectively were enrolled. The results showed HIV acquisition was reduced by 53% in Kisumu and 51% in Rakai District.

The studies above showed that the circumcision can be used as one of the effective method for risk reduction of HIV transmission. Other preventive measures such as the correct and consistent use of condom, delay sexual debut, reduced numbers of sexual partners, avoidance of penetrative sex and voluntary HIV testing and counselling must be sustained. 

In order to make sure that this procedure is scientifically and medically appropriate, clinical guidelines must be issued by the State as a compulsory regulation for circumcision procedure. This is important based on the data in one of the province in South Africa. In 1995, this province stated more than 40 deaths, 40 mutilations, and more than 1000 hospital admission due to traditional circumcision.

A piece of info...

All men undergoing male circumcision should be clearly instructed and supported to abstain from sexual intercourse until certified that their wound has healed, normally taking up to six weeks, to avoid increasing the risk of both acquiring and transmitting HIV.





References:
1. WHO, 2008.Safe, voluntary, informed male circumcision and comprehensive HIV prevention programming. [online accessed on November 15th  2010]

URL: http://www.who.int/hiv/pub/malecircumcision/guide_decision/en/index.html

2. Harrison’s Principles of Internal Medicine, 17th edition, Fauci, Braunwald, kasper, Hauser, Longo, Jameson, Loscalzo.

Avian Flu

For this session, I would post something related to bird flu that has become one of the threatening disease that would affect human globally. Avian flu is caused by influenza type A virus that infects birds and rarely human. Basically, there are 16 H subtypes and 9 N subtypes. H5 and H7 virus subtypes are known to cause highly pathogenic and can cause severe form of disease. The presence of these virus subtypes does not necessarily indicate that these subtypes are highly pathogenic and not all can cause severe form of disease. H5 and H7 subtypes are usually have low pathogenic form when it is first introduced into the poultry but can be transformed into high pathogenic form when they are allowed to circulate for several months. The H5N1 can be divided into two clades or groups (clade 1 and clade 2 viruses) that are circulating among the poultry. Subtypes 2.1, 2.2 and 2.3 are thought to infect human. At the moment, H5N1 flu does not spread to human at high rate. Most of the human cases occurred due to the direct contact between human and sick or dead poultry or dead wild bird, visiting a live poultry market. In 2004 (Thailand), there was a case in which the direct human-to-human transmission was proven due to the prolonged and very closed contact between the ill child and her mother in a hospital. In 2005 (Vietnam), the investigation suggests that the transmission of H5N1 occurred due to the consumption of uncooked duck blood. In 2006 (Indonesia), WHO has reported that 8 people were affected and 7 death was the result. In this case, the source was the   contact between first member and infected poultry. There are many more cases that are not mentioned here.

Treatment:

Basically, there is collaboration between CDC, WHO and National Institute of Health (NIH) in the development of a vaccine for influenza A. Vaccines are not produced for commercial purposes until the new virus has emerged and the disease become pandemic. There are two types of drugs available for influenza: Neuraminidase inhibitors class and M2 inhibitors class. The first class mentioned are still effective and are commercially known as Tamiflu (oseltamivir) and Relenza (zanamivir). The use of the drugs is to reduce the duration and severity of the illness if it is administered early (before 48 hours). The second class mentioned above is not that effective because of the development of resistance. The examples of the drugs are amantadine and rimantadine.

References:

1. World Health Organization, 2005. [online accessed on November 15th  2010]
URL: http://www.who.int/csr/disease/avian_influenza/guidelines/nomenclature/en/index.html

2.   Centers For Disease Control and Prevention. [online accessed on November 15th  2010]
 URL: http://www.cdc.gov/flu/avian/outbreaks/current.htm

3. CBC News, 2008. [online accessed on November 15th  2010]
URL:  http://www.cbc.ca/news/background/avianflu/

Challenges to be addressed in Malaysia in facing globalization:

Malaysia is one of the developing countries in the world that face the same problem in delivering health care service to the population. The government must know how to tackle the problem of rising demand with limited resources. In order to reduce the effect, we must clarify the specific problems, so that we can solve the problems effectively. Here are some problems related:

Increased industrialization:

Increased industrialization in electronics, electroplating plants, rubber, plastics, chemicals, pharmaceuticals and other substances related industries have led to many diseases such as occupational disease such as acute contact dermatitis and chronic contact dermatitis as well as diseases produced by the emission of toxic discharges or contamination of food change by toxic discharges. If these toxic substances are managed properly, the problems related to the effect of toxic can be reduced.

Equity, accessibility and affordability.

Even though the urban population percentages within 5 km of a static facility is higher compared with rural population, Ministry of Health has developed Rural Health Services programme to provide coverage to rural population.

  Continuous presence of illegal immigrants.



Illegal immigrants presence in our country have given to many problems in term of health as well as social and economic impact. In term of health, some immigrants do contract and spread their communicable disease contracted in their origin country.








 

Shortages and maldistribution of Human Resources.

The shortages of human resources especially for professional group in many government health care facilities is due to brain drain of the professional that prefer to work in private setting.

Quality Services.

When we talk about quality, it is basically related to human perception and preference or in order to describe the word, we could say that it is subjective things. In order to improve the quality or at least maintain the quality at the adequate level, trained health personnel must meet the basic standards or criteria in delivering health care such as technical competency, efficiency, effectiveness, appropriateness, compassion and regard to human dignity.

                                                                                          



Financial constrains.

Economics problem is a problem that is affected by global economic status as well as national budget allocation. In 1998, a year after regional economic crisis in 1997, MOH experienced 12% cut in budget allocation. However, MOH had taken several measures to sustain the health care service to the needy that is affordable and appropriate.
 

Public Health issue in India.

Today, I would like to post something related to public health. This is one of the best topic that I interest most because I really think that Public Health intervention is the better in the management of health rather than cure and rehabilitative management. Public health has its own way to reduce to long term cost of health. For this post, I would focus on the issue of public health in India. This is simply my expression and what do I understand about the articles produced by T. Jacob John and Jayaprakash Muliyil, Formerly professor and Head, department of Clinical virology.

Health Problem in India:
There are many diseases that are still become epidemic in India despite of well run intervention programmes carried out by government. Examples of the disease that are still become unsolved problems in India include malaria, tuberculosis, and leprosy. Malaria is still a problem because of the intervention to control the disease is not sustained and there is resurgence of p. Falciparum in many states. The prevalence of adult TB is still high and the incidence of TB infection in children does not decline. Even though, the National TB Control Programme has begun since 1962. Other examples that shows the failure of public health system intervention is the epidemic of chikungunya virus. As we know, this virus is transmitted by Aedes Aegypti, the same vector for dengue virus. This shows that the government intervention to eradicate the vector and control the dengue virus diseases was failed. 

  
How to improve?

 There are many interventions that can be taken when the Public Health infrastructures are widely available in the country. Public health focuses more on case-based and real-time disease surveillance, disease prevention, detection of early signal of outbreak and immediate interventional response, coordinated control and monitoring of trends of all endemic infectious diseases which may vary from region to other region, the maintenance of microbiology lab in all districts and its quality as it is very important for diagnostic purpose and management of the diseases and health promotion.  

Other than that, other States in India can learn from Tamil Nadu because of their successful projects in improving citizen health. Some of Tamil Nadu achievements include > 90 % coverage of the 3rd dose of DPT in infant for over a decade and virtually eliminated child death due to measles.

Moreover, they proposed the establishment of the Department of Public Health in both Central and States level. The establishment must be preceded by training and education process to produce enough manpower for public health infrastructure. Well-trained public health officer should be placed at both level and the interaction and coordination between two levels should be done regularly. States and districts officers are important for disease prevention and outbreak control and officials at central level are important for policy formulations, creation of protocols, standardization of public health interventions and procurement and supply of quality assured materials.

Why such infrastructure is needed?

In my opinion, poverty itself is the disease because it does not only effects people physically, but psychologically and socially as well. In order to eradicate poverty or at least reduce the rate, we need a tool that can be used to improve the health of the poor, so that their productivity can be improved. Public health is the tool. We can use one example to explain about this. Hepatitis B in treatment in Indonesia cost around Rp 1.800.000 per month but the vaccines only cost around Rp. 600.000. If we analyse this example, we can conclude that it is much saver if we prevent the disease early before we contract the disease. Let say poor people contracted Hepatitis B and they need to but such expensive medication monthly, this would make them become poorer. Prevention and health promotion under public health agenda give better long term benefits not only to poor but all citizens in the country.

On the other hands, globalization has brought many other diseases to many countries including India and Indonesia such as hypertension, diabetes mellitus, brain diseases, renal diseases, mental diseases, injuries, environmental and industry-related toxicities and genetic diseases. If the PH structures has not established immediately, we will face more diseases burden in the near future as the number of people contracting the “millennium diseases” become more and more.

References:
1. John, J.T. Muliyil, J. 2009. Public Health is Infrastructure for Human Development. Indian J Med Res 130, July 2009, pp 9-11.