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.

Be recognized!

This post would focus on the Accreditation of the hospitals in Malaysia.

History:

The Malaysian Healthcare Accreditation Programme was develeped on 1st October, 1999 when Memorendum of Understanding (MoU) was sigend by Ministry of Health (MOH), Malaysian Medical Association (MMA), The Association of Private Hospitals of Malaysia (APHM), and Malaysian Society for Quality in Healthcare (MSQH). WHO Consultant from Australia has been providing the guidelines but local needs and conditions are also incoporated in developing the process and standards.

The quality of the standards include:

1. Accessibility of care

2. Safety

3. Appropriateness and effectiveness of care

4. Patient centeredness

5. Efficiency

6. Competency of the health care provider.

Standards:

1.Organisation and Management

2.Human Resource and Management

3.Policies and Procedures

4.Facilities and Equipment; and

5.Quality Improvement Activities

6.Safety 

Acreditation process:

The Accreditation process is started with training process by MSQH. Training is needed  for the introduction of the standards to the hospital. Next, gap analysis is carried out and action needed to be taken to bridge the gap is performed. Then, self assessment is performed once the hospitals has confidence of substantial compliance to standards. The formal request to the MSQH is made after. 

 Accreditation Surveys:

 Basically, there are three process in Accreditation Surveys; Opening Meeting, Surveys and Closing Meeting. In opening meeting, the hospital management give briefing about the hospital. This is followed by the introduction of the Survey Team and briefing on the conduct of survey by chief surveyor.The survey is then conducted across the hospital including night visits. Closing meeting ends the process. In this meeting, the surveyors brief the hospital about their findings and the staff can raise any points. 

Accreditation Award:

Basically, there are three outcomes of the surveys: 3 Years Accreditation, 1 Year Accreditation or No Accreditation. The outcomes made by the surveyors on the basis of hospital performance. The reccomendation of the hospital is submitted together with detailed report to MSQH Council to decide.3 Years Accreditation is awarded to the hospital that has substantially complied with standards. 1 Year Accreditation Years is awarded for the hospital that is generally complied but there were certain areas that need to be addressed. Focus Survey can be then conducted within a year after accreditation to reevaluate the area that need to be addressed. If the hospital is found to be compliant, additional 2 Years Accreditation is awarded to the hospital. If not, the accreditation will be withdrawn. No Accreditation will be awarded for the hospitals that do not comply with the standards. 

References:

1. Abraham, M. 2007. Hospital Accreditation In Malaysia.

     [online accessed on November 10 2010]
    URL: (http://www.quality.kck.usm.my/index2.php?option=com_content&do_pdf=1&id=130)
2. MSQH. 2010. Accreditation In Malaysia. Accreditation Process.

     [online accessed on November 10 2010]

     URL: (http://www.msqh.com.my/Acc_Overview.aspx)

Looking forward for the best standard achievement

Clinical governance is one of the interesting topics to be discussed in millennium world. There are many countries in the world have started to establish and apply this concept to their hospital management. For this topic, I would share how UK NHS establish and apply this concept to their health system.
In order to discuss further about this topic, we should know the definition of clinical governance. Clinical governance is a powerful, new and comprehensive mechanism for ensuring that high standard of clinical of clinical care are maintained throughout the NHS and the quality of service is continuously improved.

Basically, in order to run this programme successfully, the clear elements must be developed and elaborated in more details. So that all people involved in service delivery understand clearly their role and responsibility. Elements included are risk management, openness, research and development, education and training, clinical audit and clinical effectiveness. 

There are two organizations that set the standard of care in UK. National Institute of Care Excellent sets the standard of care via wide consultation and research into the clinical effectiveness and cost effectiveness of the clinical practices. National Service Framework includes care target such as services for elderly and coronary heart disease.

Clinical governance is monitored by Commission for Health Improvement (CHI) by visiting the healthcare every four years and the individual review is made widely available. Other organization is NHS Regional Offices that is responsible for monitoring the implementation of the standards nationally as well as for monitoring the overseeing of the implementation of action plans. NHS Performance Assessment Framework is important to monitor the performance of individual organization so that we can compare between organizations. These organizations are required to produce annual report as well as planning for quality improvement for the following year. Annual surveys are also conducted to receive feedback from the patients and users’ experience.

References:

1. Zahir, K. 2001. Clinical Governance in the UK NHS. DFID Health System Resources Centre. UK.
2. Starey, N. 2001. What is Clinical Governance? (Volume 1, Number 12)

Giving hands to the poor.......

Indonesia is one of the developing countries with 14 % poverty rate. According to this data, we could conclude that more serious intervention should be focussed on the poor in Indonesia. Poverty should be looked as one of the serious aspect in the country. If this problem is not managed properly it can lead to general health status as well as human resources problems. Such a waste!

In this post, I would try to give some information related to some measures that are taken by government of Indonesia in providing health insurance to the poor. These are four existing social security schemes in Indonesia:

(a) Jamsostek – Jamsostek is a private insurance fund that provides insurance for the private sector employers and its employees. There are four basics coverage; Injury employment, Death, Health Insurance, and a provident fund type Old Age Benefit.

(b) Taspen – Taspen provide fund for civil servants in the form of a retirement lump-sum or a pension programme.

(c) Askes – Askes provide Health Insurance for the public sectors employees and some others.

(d) Asabri – Asabri provide counterpart fund for the armed forced and police in the form of a retirement lump-sum or a pension programme.

                                                  

In 2005, Kartu Sehat that was formerly provided fund for the poor was replaced by a new Health Card system that was issued by Askes. The programme for the poor is known as Askeskin. In this programme, government is the one who is responsible for paying the premium as much as Rp 5 000 for each person per month. It was estimated that annual contribution of this programme to be 3.6 trillion for 60 million people. There were two phase in 2005. The first semester occurred between January and May 2005. The period targeted 36.1 million individuals covered that was equivalent to the number of estimated poor people in Indonesia. Askes ran this programme through its local branches. The local authorities provided the list of qualifying people. Basically, the number of qualifying people in the list must be consistent to the estimated quota given to the districts. The services provided included outpatient primary care in local health centres (Pukesmas) and free treatment at the hospital, generally 3rd class public hospital. For the second semester (June to December 2005), the target was 60 million individuals to cover the poor and near poor people. There was a change in term of fund management. The fund was directly paid to the District Health Office for the Puskesmas service and Askes only received payment for the hospital service provided to the poor.

References:

1.International Labour Organization. Indonesia: Providing Health Insurance For the Poor.



   

Drugs : Cross-Level Services and Inputs.

Drugs are important in delivering effective health intervention. Over the past 50 years, there are many drugs available for the prevention of the disease such as polio and measles, for treating viral and bacterial infection such as Zidovudine (antiretroviral drugs for the treatment of HIV) and TB drugs, for the treatment of chronic diseases such as CVD, depression and diabetes, as well as for the palliative care. Some issues must be taken into account when we are considering about the delivery of appropriate drugs for those who need them.

a. Financial issues
Financial issues include funding for basic research and commercial development, defining and protecting intellectual property rights, and assuring affordability. Basically, basic research and commercial development of the drugs can be found mostly in the developed countries. The main problem for this is the drugs produced by these developed countries are mostly focussed on their disease burden. This is proven by the fact that out of 1, 325 new medicines available between 1975 and 1997, only 11 drugs were specifically developed for tropical disease such as TB and malaria. Some international measures have been initiated since past decade such as Doctors Without Borders’ Drugs for Neglected Disease, public research into developing vaccines for malaria and new therapies for drug-resistant TB.

Other than that, assuring affordability of the drugs is also important in financial issues. This is because, if the drug is too expensive, it cannot be purchased by the patient, so the effective health care intervention cannot be achieved. One of the solutions for this problem is the use of the essential drug list that is listed by WHO. Basically there are 320 essential drugs in 559 formulations in WHO guidelines. Essential drugs are important because it focuses on the least expensive alternative in order to treat the categories of diseases that are prioritized. Essential drugs list varies among countries. According to WHO, essential medicines are those that satisfy the priority health care need of the population. The criteria for the essential medicines include the availability of the medicines in sufficient amount, affordable, in appropriate dosage form and assured quality.

b. Logistical issues
Logistical issues include procurement, storage and distribution. Procurement process mainly focus on three things; the quality of the drugs, the price and the reliability of the supplier. This process follows strict tender in which the lowest price is not the main indicator for primary selection. In this kind of tender, the bidders are required to send info related to companies reliability, production quality, financial stability, and their past performance. The price of the drugs would be decreased with time. This is because of several factors such as when the patent protection expires, when the compulsory licensing is enacted, and in the conditions in which there is public pressure, collective negotiation or international advocacy. After the drugs are purchased, it is important to transport the drugs properly in order to maintain the quality of the drugs and prevent damage of the drugs. The drugs must be stored properly.  

c. Clinical issues
Clinical issues here concern about the appropriate prescription practices and adherence to the regimen prescribed. There are two main problems related to the failures in drug therapy; the failure of the patient to comply the correct dosage and the duration of the drug therapy; the wrong prescription by medical staffs. Some of the medical staffs tend to prescribe the drug unnecessarily. Both of the factors above have devastating effect on the effectiveness of health care intervention because it can accelerate the emergence of drug resistant microorganism such as the case of TB. The emergence of drug resistant microorganism could really cause major negative impact on middle and low-income countries because this problem occurs mostly in the countries mentioned above but not the developed countries. Most of the basic research as stated somewhere in this topic, is carried out in the high-income countries.

d. Incentives issues
 Basically, these issues are related to the drug research, development and marketing that affect the involvement of pharmaceutical companies, private health care providers, pharmacies, and publicly financed or managed health services.

References:
1. Jamison, D.T., Breman, J.G., et al. 2006. Priorities in Health. World Bank, Washington, DC.
2. Who Health Organization. 2010. Essential Medicines. [online accessed on Nov 3 2010]

The Effect of Decentralization on Health System

Indonesia:
 

The challenges. 

Decentralization has given more power and authority to local government to allocate the fund provided by central government and manages their own health system locally. This system has resulted in some advantages in certain local governments and disadvantages in others region. In order to run this system successfully, the elected officials must have knowledge related to health system management. Basically, local governments are willing to pay contracted amount for medical education. This is due to general perception of society that always relates health to medical disciplines. This condition could lead to other negative impacts on medical field that will be elaborated later. Health can be divided into personal and public. Most of the people are concerning about personal health that focus more on curative and rehabilitative management rather than public health system focus more on preventive and promotion measures. Other than that, local government also concern about the shortage of the medical officers rather than closing the gasp for deployment of public health professional. Moreover, some institutions planners simply looked at the MOH prediction for Human Resources for Health (HRH). The ratio is one HRH for 100 000 population. This ratio seemed to be simplified from other developed countries without considering about other aspects such as local government fiscal capacity, overall resources requirement and the need or demand for service. If these factors are not considered properly, its can lead to the overproduction of the HRH. In certain developed countries such as UK and Germany, this ratio could produce very good impact on their health system. In both countries mentioned above, the ratio of one family physician is for 2500 people.  In those countries, the presence of the formal health insurance in Netherlands and state’s role as insurer under National Health Service system in UK lead to the high demands of family physician services. Basically, overproduction can increase the unemployment rate and supplier-induced demand. This has deleterious effect on society because it can increase moral hazards in term of overutilization of medical, nurse personnel and etc. Even though, Indonesia is included in the list of countries with critical shortage of medical workers, the massive increase in term of quantity of the HRH will somehow give small impact on health system. This is due to the uneven distribution of the HRH between the regions. One of the factors that lead to the uneven distribution is lack of economic incentives by public health sector.

Learning from the other countries ........ 
 

Incentives Payment in China. 

In 1980, most of the village doctors in China practiced privately because of the collapsed of the commune based insurance schemes and the local government did not provide salary to the doctors. This condition led to some difficulties in TB treatment programme. Even though the drugs for TB are free, village doctors relied on payments for drugs and services. This had caused some problem because village doctors are important in diagnosis, treatment, and surveillance. The government had created incentives schemes for the doctors. US$ 1 would be paid for every patient enrolled in TB treatment programme, additional US$ 2 for every smear examination carried out in the county TB dispensary at 2 months and further US$ 4 for each patient completing the treatment. In order to ensure the quality of the treatment and reported information, random visits and examination were carried out. The reporting system monitored the performance. This intervention was highly successful with 2 years cure rate for new cases for TB was 95%.

References:

1. Jamison, D.T., Breman, J.G., et al. 2006. Priorities in Health. World Bank, Washington, DC.
2.  Thabrany, H. 2006. Human Resources in Decentralized Health Systems in Indonesia: Challenges for Equity. Regional Health Forum (Volume 10, Number 1). [online accessed on October 24th 2010]

URL: http://www.searo.who.int/LinkFiles/Regional_Health_Forum_Volume_10_No_1_08-Human_Resources_in_Decentralized_Health_Systems.pdf