Friday, December 3, 2010

Travel Medicine

          First time, I come across the word "travel medicine". From the word itself, it is not hard to deduce that it is about medicine or something to do with travelling, pretty easy ha? Now, please elaborate more. Medicine = drugs? vaccine? travel? aeroplane? Bali island? Okay, so much for the brain storming.

           In fact, travel medicine is a branch of medicine that deals with the prevention and management of health problems of international travellers. Interesting isn't it? More people travelling, travelers are seeking more exotic and remote destinations are the logical reason behinds this branch of medicine. Studies show that 50- 75% of short term travelers to tropics may have medical problem after their return home. 5% of the cases would require medical attention, and less than 1% need hospitalization. To be suprised, cardiovascular disease and injuries ( *traffic accident) record the most common causes of death among travelers.

           Commonly, health advice for international travel would be immunization or vaccination especially to those long- stay travelers. According to Harrison, there are three broad categories that clasify immunizations for travel. The 3 Rs.
1) Routine immunization : childhood/ adult boosters that are neccesary despite no travel
2) Required immunization : immunizations that are mandated by international regulations for border crossing
3) Recommended immunization :immunizations that are desirable due to travel-related risk
If you are interested to know the full desciption of these immunizations, please refer here.
         One more interesting information to share. For a short term traveler, they are advised to bring traveler's medical kit with
1) an anelgesic,
2) an anti-diarrheal agent and an antibiotic for self- treatment of travelers' diarrhea,
3) antihistamines,
4) laxative (wonder what is this for?)
5) oral rehydration salts,
6) a suncreen with a skin-protection factor of at least 30, ( specific huh?)
7) insect repellent, an insecticide for clothing ( permethrin),
8) and if neccessary, an antimalarial drug.

For long- term traveler, they may add

9) a broad-spectrum general purpose antibiotic (levofloxacin or azithromycin)
10) an antibacterial eye and skin oitment
11) a topical antifungal cream

          What a long list! and it is just traveler's medical kit ?! Lastly, fun things to share today, self treatment of infections for the long-stay traveler:
1) "below the waist" ( bowel and bladder infections) : antibiotics, once daily, 3 tablets
2) "above the waist" ( skin and respiratory infections) : antibiotics, once daily, 6 tablets

          Unbelieveable, isnt it? I mean, if this really work, everyone can be their own doctor, ha. Just so to know, the above information is taken from a reputed reference book, Harrison. Anyway, risk disclaimer here: anything happens, the author of this blog is not responsible.  

1) Lecture note by dr. Tri Wibawa : Travel Medicine
2) Harrison's, Principles of Internal Medicine, 17th edition, page 783 - 4

Thursday, December 2, 2010

Surveillance System

           Lately, the word "surveillance" keep popping out in our tutorial discussion. We have disaster surveillance for week 6 scenario, communicable disease surveillance, non-communicable disease surveillance and blah blah blah for week 3 scenario. So what is surveillance? As usual, lets clarify the word  `surveillance'. According to CDC, (Centers for Disease Control and Prevention),

         "Surveillance is the ongoing, systematic collection, analysis, interpretation, and 
           dissemination of data regarding a health-related event for use in public health   
           action to reduce morbidity and mortality and to improve health".

"Data disseminated by a public health surveillance system can be used for immediate public health action, program planning and evaluation, and formulating research hypotheses", added by CDC. A lot of words to read huh? Ok, let picture do the job.

            This is the surveillance system in public health. What about applying it onto communicable disease, non-communicable disease, and disaster? If you understand the description above, it wouldn't be hard to apply the knowledge elsewhere. On the lecture about communicable disease surveillance,  Dr Rizka has gave a clear picture about malaria surveillance in Indonesia. Today, I am going to talk about TB surveillance. Hereby, I will answer a question which Dr Rizka threw at the end of lecture. The question sounds like this " data apa saja yang dibutuhkan untuk mensurvey TB????."  Answer will be revealed as you continue reading this blog.

           First, allow me to say something about the background of TB. TB is one of the world’s deadliest diseases as one third of the world’s population are infected with TB. Over nine million new cases of TB, and nearly two million deaths from TB, are estimated to occur around the world every year. Besides, statistics has shown that approximately 95 % of TB cases and 98% of TB-related deaths happen in developing countries. The reasons that the TB programme record not much success are believed to be caused by less commitment by governance and financing system, an insufficiency of TB control services and TB cases management within the community, a wrong perception of benefits and effectiveness of BCG and last but not least, health facilities established by those developing country is limited in terms of quality.

           Apparently, TB surveillance data are essential to evaluate the effectiveness of TB control programs, identify deficiencies, and assess interventions in order to control and eliminate TB. WHO has enhanced DOTS initiative and the CDC emphasize the importance of monitoring and evaluating surveillance program performance. Back to the flow of surveillance data, collection of valid,complete and right TB surveillance data would play an important role at the beginning. Of course it is, if no good data collection, how to utilize the data optimally for the rest? To answer dr's question, below are the examples of data I think would be helpful for TB surveillance system. It may not cover all data nessary or I could be wrong, correct me if so.

 * How many people died from TB?
 * How many cases of TB were reported?
 * How TB is transmitted?
 * Review of bacteriology, sputum culture, chest X-ray, drugs susceptibility test results
 * Survey regarding demographic features, environmental, social or behavioral risk
    factor, public general knowledge, attitudes, and etc..
 * Reports on severity of disease, previous anti TB status and site of TB infection site

       Next, surveillance data collected is compiled and analyzed by time, place, and person. Simple tables, maps, charts, and graphic are useful to summarize and present data in percentages or rates of disease cases. For instance, the chart below shows the TB case detection and treatment success rate  in Indonesia from 2003- 2007.

From the chart, we can interpret whether TB control measures are succeeding and where increased efforts should be focused. Thus, TB surveillance data is essential to improve our understanding of the true epidemiology of the disease as well as to increase our knowledge as to what factors might contribute to eliminate and control TB.

     Lastly, dissemination of data to those who make policy and implement intervention programs is critical to the usefulness of surveillance data. For example, TB surveillance system may provide important information on trends in the multi durgs resistance (MDR) therefore policy maker can make changes in prescribing drugs to TB patients. Besides, dissemination of surveillance data is useful for risk communication and education to health care professionals, the media and the general public. In conclusion, surveillance systems include the capacity for data collection and analysis, as well as the timely dissemination of information to persons or group of persons who can undertake effective prevention and control interventions related to specific health outcomes.

1) Lecture note by Dr. Rizka Humardewayanti: Communicable disease Surveillance

Tuesday, November 30, 2010

Medical Logistic For disaster

             In conjunction to the practical session about medical logistic for disaster I am going to have tomorow, I have done some reading on logistic management in the setting of disaster.

             First, lets clarify the key word "logistic". What is logistic? The word "logistics" comes originally from the military procedures for the procurement, maintenance, and transportation of materiel, facilities, and personnel. Generally, logistic refers to "a system whose parts interact smoothly to help reach a goal promptly and effectively thanks to the optimized use of resources". According to Pan American Health Organization-WHO,2001,  "logistics are required to support the organization and implementation of response operations in order to ensure their timeliness and efficiency in emergency relief operations."

           Besides, PAHO-WHO has classified the logistic items into ten classes as below.
1. Medicines;
2. Health supplies/Kits;
3. Water and environmental health;
4. Food;
5. Shelter/Electrical/Construction;
6. Logistics/Administration;
7. Personal needs/Education;
8. Human resources;
9. Agriculture/Livestock;
10. Unclassified. ( * supplies that may have expired, can't be identified due to poor  labelling,etc.,are useless, have spoiled or were packed too dangerously  to be sorted out.)

Basically,in the health sector, the logistic items are categorized into two main groups: - medical logistic and non-medical logistic. Medical logistic comprises of medicines and health supplies/kits. The rest are put under non-medical logistic. Ok, now back to the main topic I am going to talk about here.

            When a disaster strikes, loss of life or injury are events that are unavoidable. To preserve life or health of the disaster victims, it is essential for the drugs and medical equipments to be readily available in sufficient amount . Besides, the authority must optimize the use of all the resources, by storing and distributing the medical supplies in such a way that their quality are assured and that they are used rationally. In short, medical logistic is managed through the process of  selection, procurement, storage, and distribution. In fact, the support from organizations and regulations of work, human resources, information system and financing system is neccesary to run the management in a effective manner.

             Initially, a selection committee which comprises doctors, nurses, pharmacists, and representatives of the ministry of health will work together to develop a list of basic and critical medical supplies to be provided to the affected population. The selection criterias such as health care needs, the characteristics of the patients who require treatment, the availability of supplies and the capacity of the health system are taken into account. For instance, various countries will have their own list of basic drugs and medical products to respond to those health problems happen in the disaster. If no such list present, reference could be made from WHO- standard list of essential drugs and medical supplies for use in emergency situations.

Sample of basic drugs for Emergency Use ( by WHO) 

         Next, the drugs and other medical supplies is procured to ensure that the quantities are enough to meet the health care needs of the affected population. Besides, the quality of supplies is guaranteed and its availabilty at the time disaster happens is established. In order to anticipate or estimate the needs for supplies, a few methods or formula can be used. Below is one of the example of the formula.

             OPTIMAL STOCK = (WS + SO + LT + BS) - S
                                WS  = working stock
                                 SO  = stock out
                                 LT   = lead time
                                 BS  = buffer stock
                                  S   = stock in hand                                     ( DepKesRI, 2007)
           In addition, adequate storage conditions may make sure that health supplies retain their quality and effectiveness by creating the necessary physical, hygienic and infrastructural conditions. Besides, keeping track of stock level and monitoring regularly the expired dates of stored drugs could help in maintaining an optimal use of the available resources. Below is an example of approach for stock controlling.

                                      Fixed Order Quantity Approach: `Q' model

The above approach signifies that the order quantity can be fixed at a level depending on demand(D), value and inventory related costs. A stock level called Re Order Level (ROL) is fixed, which triggers ordering. ROL happens when safety stock/ buffer stock is sufficient to fulfill the demands rate during lead time . This approach order quantity is fixed by calculating Economic Order Quality(Q) and ROL is fixed by calculating lead-time consumption.

             Lastly, in disaster situations, a proper distribution of drugs and other medical supplies is done based on the demand for them and on the existing stock level. To ensure that the medical supplies are delivered at the right time and to the right person, the various organizations receiving supplies must coordinate their efforts, particularly with government agencies responsible for health care, such as the ministry of health. Few measures such as the availability of a reliable transport system to deliver the medical supplies, education to the patients about correct drug use and monitoring shall be carried out, the appropriateness of delivery schedules need to be considered for distribution to be conducted effectively. 

1) Lecture Note by Dr Sulanto Saleh- Danu: Logistic( medical) and Disaster


Sunday, November 28, 2010

Disaster Management in Indonesia

             Indonesia, a vast archipelago of 235 million people, is prone to both natural and human-made disaster. Below are the organizations which take care of disaster management in Indonesia.

             In certain cases, prevention could be carried out to avoid or to minimize the adverse impact of a  disaster.  Mitigation involve structural and non-structural measures undertaken with the aims of decreasing overall risk of a disaster. Structural measures refer to any physical construction, for instance, construction of hazard-resistant or protective infrastructure. Non- structural measures denotes policies, awareness, provision of information, participatory mechanisms and etc. In addition, preparedness which means to anticipate the occurence of disaster, require supports from the organization. For instance, space technology set up by the organization can help in hazard and risk mapping.

            If there is forewarning, certain aspects of the response may take place even before the disaster. Unfortunately, the disaster is well-known for its unpredictability, speed and swiftness. When a disaster strikes, emergency response or acute medical response may play an important role. For example, medical professionals who do preservation of life and health to those injured victims can minimize the death toll in the disaster. If confronted by numerous patients simultaneously in a disaster situation, it is easy to become overwhelmed, even for an experienced disaster worker. Hence, medical personnel are accustomed to apply the concept of triage which involves providing the most help for as many as possible.

            After a disaster, the recovery phase is crucial for the affected community and it could be a long term work to do. During this phase, actions taken aim to restore or improve the living conditions of the stricken community as well as to encourage necessary adjustments to reduce disaster risk. The recovery phase consists of rehabilitation and reconstruction. For instance, rehabilitation may involve scene withdrawal to ensure the operations of public services and community life run effectively. Whereas, reconstruction happens when the the condition of public services and community life is restored, or become even better than before the disaster. This recovery process may take place in the forms of physical, social, and economy.

          Generally,  disaster management refers to "the aggregate of all measures taken to reduce the likelihood of damage that will occur related to hazard(s) and to minimize the damage once an event is occurring or has occurred and to direct recovery from the damage."   In conclusion, the phases of disaster management can be categorized based on the disaster cycle: before, during and after the disaster.

1) Lecture Note:  by Dr Hendro Wartatmo :
     Conceptual Framework of Disaster& Disaster Management

Saturday, November 27, 2010

Pathophysiology of Disaster

            On Tuesday afternoon, Indonesia has raised the alert level at one of its dozen of volcanoes, Mount Bromo to “beware,” the highest alert level before an eruption. I am lucky enough to have visited Mount Bromo on my first year study here. I still remember that the entire top of the mountain has been blown off and the crater inside constantly belches white sulphurous smoke. The view is really breathtaking. Mount Bromo is 275 km east of Mount Merapi, which in the past month has unleashed a series of powerful eruptions leaving more than 300 people dead. The volcano's initial blast occurred less than 24 hours after a tsunami swept through the remote Mentawai islands, killing at least 428 people.

MOunt Bromo shoots ashes into the sky

MOunt Bromo Behind Me

               Indonesia is situated along the Pacific Ring of Fire that leaves it vulnerable to earthquakes and gives it more active volcanoes than any other country. Not only in Indonesia, a disaster happens somewhere in the world almost daily. In the lecture, conceptual framework of disaster, Dr Hendro Wartatmo said that the word disaster is broadly defined. The UU Republik Indonesia no 24 Tentang Penanggulangan Bencana states that a disaster is an occurence which can be induced by natural, non-natural or manmade forces that negatively affect life and causes loss of life or injury, environmental degradation, property damage or psychological impact to the community.

              At the beginning of the lecture, Dr Hendro showed us a scenario about Mount Merapi eruption. Later, the scenario is split into sentences. We were asked to match some terms of disaster pathophysiology with the sentences. All of the terms were not new to us but it is not easy to match them as they have similar meaning one to another. Below is the pathophysiology of disaster with the terms.

Hazard à Event à Impact à Damage

             A disaster happens starting with the hazards. Hazard is something contains energy or to be accurate, a potentially physical event, phenomenon or human activity which can bring destructive effect to a given area or community. There are natural hazards (geological, biological, etc.) as well as human-induced hazards (environmental degradation and technological hazards). Risks come in between hazard and event. Risk is defined as the probability of harmful consequences, or expected losses resulting from interactions between natural or human-induced hazards & vulnerable conditions.
Conventionally, risk is expressed by the notation:
                                          Risk  = Hazards x Vulnerability.
To describe disaster risk reduction, the concept of capacity which refers to a combination of all the strengths and resources available within a community that can reduce the level of risk or the effects of a disaster is included. Below is the modified notation.
   Risk =     Hazard x Vulnerability              
Event comes after hazard or risk. Event is the realization of hazards which is followed by the impact. The term impact indicates the  contact between an event and society. Unavoidably, the impact of an event would lead to damage. For instance, damage may refer to a change of social functions within a community. 

                According to WHO, a disaster happens when “a sudden ecological phenomenon of sufficient magnitude to require external assistance ".  To differentiate between event and disaster, the keyword is that disaster calls for external aids in order to restore the pre-disaster living condition or to return to normal operations of the community while the event needs no external helps. When a disaster strikes, its destructive effects would overwhelm the ability to meet the demand for health care, as The American College of Emergency Physicians (ACEP) has pointed out. For this reason, a proper disaster management which involves pre-disaster planning, organizing, controlling, feedback and corrective action must be carried out.

1) Lecture Note : by Dr Hendro Wartatmo
    Conceptual Framework of Disaster & Disaster Management   

Friday, November 26, 2010

Chronic Disease Management in PHC

      It's been a long time since I wrote my last blog. I guess the reason is that I use “I am tired” as an excuse for being lazy and having no drive to study. Lately we all have been very busy with the packed schedule. We finished our class around 5 pm almost every day. Today, after preparing for my week 4 tutorial, I decided to put up a blog post regarding what I have read for the scenario. Dr Jati, as the recent graduated medical doctor in the scenario, has faced some problem in managing a diabetic patient during his first day working at the primary health Care Centre (PHC). The keywords of this scenario would be primary health care, team work, and chronic disease management.

      First of all, primary health care (PHC) defines community-based health services that are usually the first point of contact that patients make with the health services. As we know, the health care workers who work as a team in PHC comprise of multi- professional background. They are general practitioners, nurses, pharmacists, midwives, administrative officers and so on. In terms of professional team, each health care worker is responsible for different tasks. They have the obligations to cooperate with other health care team members in delivering health services. None of them shall do an overlapping job or duplication one to another. Whereas, each of health care team has their own professional standard, own professional culture and own  professional mechanism.
'multi- professional background in Puskesmas'

       There's often blurring of lines among one professional roles and responsibilities working in a team. Task shifting in the health care settings might happen as a response to health workers shortage. For instances, if there are many patients waiting and doctors couldn’t handle them all, experienced nurses would be allowed to prescribe medications. Hence, teamwork, also known as collaborative approach ought to be carried out to tackle the above problem. Effective collaboration involves rational distribution of tasks among health workforce teams. Everyone would understand their specific roles and work for one common goal and orientation. This is just one of the examples where team work would make more efficient use of the available human resources for health.

       In the scenario, the patient suffered from diabetes (an increasingly prevalent chronic disease) come for a visit to the PHC. So, why primary care? A.A Rothman and Edward HW (2003) have suggested a few reasons. First, most patients with chronic disease has less severe condition. Moreover, these patients often need a limited number of widely used and relatively nontoxic medications. Therefore, PHC can readily meet their clinical needs. Third, primary caregivers usually have more general training and clinical experience. This would be an advantage for the patients as most of them have more than one chronic condition. Forth, primary caregivers, especially recent graduates undergo more training in educating patients about behavioural change and self-management support. This is a key to comprehensive chronic disease management.

      Nowadays, more and more patients with chronic disease seek health care in PHC, there must be some system changes which PHC could adapt to support more effective chronic illness care. A Cochrane Collaboration review (2001) concluded that four areas where interventions implemented to improve diabetes performance in PHC have reached a success. First, activities directed at changing health workers’ behaviour. For example, clear guidelines and sufficient expertise would help the doctors making clinical decision. Second, changes to the organization of practice. Strong leadership, appropriate incentives and effective improvement strategies are important to maintain a health care organization. Third, information system is enhanced so that patients’ knowledge, skills in handling chronic illness would be improved. Last but not least, educational and supportive programmes are targeted at the patients to achieve an effective self-management support.
"System changes to improve quality of chronic care management"


1) Rothman A.A. & Wagner E.H. 2003. Chronic Illness Management: What is the Role of 
    Primary Care? Ann. Internal Medicine 2003; 138:256-261

    Care. 2001;24:1821-33.

     HSR Implementation Science,2009, 4:22.

Wednesday, November 24, 2010

What is Managed Care?

           Corresponding to my previous blog post, here I would like to explain why managed care health plans is recommended. First, lets see what people define "managed care". 

" Managed care combines financing and delivery of health care in a single entity with the aim of
improving quality of care while controlling costs."

Bashir mamdani, Meenal Mamdani ( Managed care in the USA: history and structure)

         A reminder here, the problems within health insurance system that I have mentioned in my previous post. First, non-insureds can't afford high expenses on health care. Second,quality of care in public health centers is impaired due to lack of competition or its status as non-profit clinic. From the definition above, we know that managed care aims to reduce the costs of healthcare and to ensure continuing quality of care. Thus, by implementing managed care, it is hoped that the problems would be solved. " Kill two birds with one stone" so goes this adage, seriusly, is it that easy?

               Lets have a look how managed care works. Basically, the concept applied in managed care is to modify doctors' (or other professionals initiating care) actions in giving healthcare. This is to eliminate inappropriate treatments and to ensure a cost-effective healthcare practise provided. Below are the examples of measures which can be carried out to support managed care.

1) Developing networks and seeking preferred providers. Standards in selcting providers are established.
2) Financial incentives to encourage health providers to pratice more efficiently.
3) Establishing clear guildlines to help in making clinical decision.
4) An emphasis on preventive medicine
5) Using utilization review and quality improvement programmes.

          I believe that the above measures are not hard to be understood, except for the last one. What is utilization review? It is actually a retrospective review where treatments or services given that are recorder in medical files, are re-evaluated in comparison with treatment guidelines. Usually, this utilization review is used by the insurance company to determine clinical guidelines for a given condition. 

       So much for the ideal ways of how managed care works. The reality is that there is still some problems existed within this system. For instance, in Indonesia, Askes is one comprehensive social insurance scheme which is conducted based on managed care system. This programme is compulsory for civil servants (PNS, PTT, etc.) either still working or retired , retired military and police officers, veterans, and national patriots and their families to take part by making payment or premium and get a Kartu Askes. 

       Generally, managed care has some disadvantages due to the limited capacities:-
1) patient's access to care and their freedom
2) provider's ability to decide which diagnostic test and treatment to be ordered.

          The patients who pay premium to be covered by Askes will go the healthcare centers insured by Askes. Sometimes, the health facility or health services doesn't meet the patients' expectation. For instance, the bed in hospital is not enough, doctor always come late and so on. Those patients who can afford, may choose to go private healthcare centers. Indirectly, this mean Askes programme has failed. Besides, patients found out that the drugs given are not paid by Askes sometimes. Why this is so? That is probably because some doctors has some kind of cooperations with private pharmaceutical company who agree to accept extra profits- the incentives. Again, the  patients become dissapointed over the insurance programme.

          In the lecture, Pak Gatot Subroto from PT Askes Jogja has said that Askes programme need support from the community, only if Askes make more than 50% of the hospital income, Askes could make some changes in those healthcare center.  I think that it is more efforts should be implemented to cope with the internal problems within the hospital itself first. If patients found those hospitals or puskesmas provide a good quality of health care at minimum cost, they wouldn't have hesitated to get themselves insured by Askes.

1) Lecture note by Pak Gatot Subroto :Managed care