Environmental factors and an eco-epidemiological model of malaria in Indonesia

02/09/2012

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Institute of Resource Governance and Social Change

Producing Knowledge, Inspiring Policy Innovation and Change

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Acknowledgment • • •

Environmental factors and an eco-epidemiological model of malaria in Indonesia

Semua korban/penderita malaria Responden + Data Collector Tim Tim Entomolgist di lapangan • • •

Timor (Agus Samol+Imanuel Tamelan) + Kebumen (Agung C) + Sukabumi (Maman S) Dinkes Prov NTT, Dinkes Kab se-Daratan Timor, Dinkes Kebumen, Dinkes Sukabumi BPRV Salatiga

•

Pembimbing:

• • • • •

Penyandang Dana: ARC (Discovery) Grant Commonwealth of Australia School of Environmental Planning - Griffith University FAN IRGSC think tank members Bappeda NTT

• •

Griffith University: Prof Pat Dale, A.Prof Neil Sipe, Prof Clyde Wild Indonesia: Prof Sugeng M (UGM) + Dr Damar T Bowono (Litbang Kemenkes)

Ermi Ndoen 1st Lunch Seminar of IRGSC – Kupang, 24 August 2012. Website: http://www.sustainability-k-governance.net/index.html

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1st Lunch Seminar of IRGSC – Kupang, 24 August 2012. Website: http://www.sustainability-k-governance.net/index.html

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Ho ho ho … Saya nyamuk Malaria

Topik diskusi hari ini …. • Permasalahan Malaria  dikaitkan dengan konteks NTT • Research Fokus • Hasil dan Diskusi • Rekomendasi • Penutup


No animal in the world has touched so directly and profoundly the lives of so many human beings. For all of history and all over the globe she has been a nuisance, a pain, and an angel of death. Mosquitoes have felled great leaders, decimated armies, and decided the fates of nation. …

Nama saya Anopheles

(Spielman & D'Antonio, 2001, p. xv,– “Mosquito - the Story of Man's Deadliest Foe”)


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Pembunuh terbesar sepanjang masa


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Malaria dalam Angka 3.3 Miliar 106 24 Juta

Tidak sekadar Angka kesakitan dan kematian Orang terkenal yang mati atau sakit malaria Source: http://www.malariasite.com/malaria/history_victims.htm


Penduduk Dunia yang tinggal di daerah endemis malaria (WHO, 2010) Negara Endemis Malaria  Indonesia termasuk top 10 Negara Endemis Malaria Kasus malaria (confirmed) di seluruh dunia, 2010

325 ribu

Jumlah kematian akibat malaria di dunia, 2010

230 Ribu

Jumlah Kasus Malaria (Confirmed) di Indonesia, 2012

432

Jumlah kematian akibat malaria yang dilaporkan di Indonesia, 2010

Malaria berdampak pada

• • • • • • •

40 % public health expenditures (WHO, 2009) 30-50 % inpatient hospital admissions (WHO, 2009) 60% outpatient visit at Health Centers (WHO, 2009) 1.3% reduction in economic growth (WHO, 2009) 12 % reduction of income (WHO, 1998) 3-8 % School absenteeism (Trape et al, 1993) Indonesia lost US$ 56.5 juta per tahun (UNDP, 2004)


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http://gamapserver.who.int/gho/interactive_charts/malaria/cases/atlas.html

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http://gamapserver.who.int/gho/interactive_charts/malaria/cases/atlas.html

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Malaria = Penyakit infeksi protozoa dari genus Plasmodium Ada lebih dari 50 jenis parasit Plasmodium, hanya 5 yang menularkan malaria: 1.

P. malarie (Golgi, 1886  Italia)

2. 3.

P. vivax (Golgi, 1886  Italia) P. falciparun (Celli & Marchiava, 1890)

4. 5.

P. ovale (Stephens, 1922) P. knowlesi (Singh et al., 2004; Cox-Singh & Singh, 2008) Types of Parasite P. vivax

Agent factors

Geographical Distribution  

Penyebaran luas pada daerah tropis dan subtropis P vivax banyak di temukan di Indonesia

P. falciparum



Penyebarannya luas terutama pada daerah tropis dan subtropis.

P. malariae



Penyebarannya luas, tapi mengelompok pada lokasi geografi tertentu (cluster).

P. ovale



Kebanyakan di daerah tropical Africa, terutama di Pantai Barat Afrika

P. knowlesi



Serawak – Semenanjung Malaysia


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Producing Knowledge, Inspiring Policy Innovation and Change The geographic distribution of ten important malaria vectors in Indonesia

Host (Pejamu)

• Manusia (host intermediate) • Nyamuk Anopheles (host definitive)


(MoH, 2005)

   

>400 Anopheles species di dunia ~ 80 Anopheles species yang dapat menularkan malaria Ada ~ 24 Anopheles species malaria di Indonesia Ada ~ 10 Anopheles species dominant malaria di Indonesia (O'Connor & Soepanto, 1989; Takken et al., 1990; Laihad, 2000).

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Usia : anak > rentan Jenis kelamin : ibu hamil dpt anemia > berat Ras: ada ras dg kekebalan alamiah Riwayat malaria sebelumnya Cara hidup : sering di luar rumah malam hari Sosial ekonomi : sosek di daerah endemis erat hubungan dg infeksi malaria Status gizi : gizi < baik rentan infeksi Immunitas : immunitas alami bisa terbentuk jika tinggal di daerah endemis

• •



Impact of malaria in pregnancy

Manusia (host intermediate) • • • • • •

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Pregnancy -Increases susceptibility -More infections -More severe

Pregnant woman -Asymptomatic to acute clinical illness / death -Severe anaemia

Effects depend on -Malaria endemicity -Maternal age -Gravidity -HIV status

Foetus -Miscarriage -Stillbirth -Low birth weight (2x) IUGR / Preterm Longer term effects -Neonatal and post neonatal mortality -Immune modulation (susceptibility) -Infant anaemia -Infant growth? -neuro-cognitive development?

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Beban Malaria Pada Kehamilan



Data Pendukung (2) lanjutan…

Sumber : Poespoprodjo,dkk;2008 (RSMM Timika 2004 – 2008)

1. Malaria Pada Ibu Hamil

3. Bayi Berat Lahir Rendah (< 2500 gr) Ibu dengan Malaria : OR = 1.9 [95%CI 1.6-2.3],p<0.0001 Ibu dengan Pf -182g [95%CI: 146-217], p<0.0001 Pv -108g [95%CI: 56-161], p=0.003

18% (808/4419) Ibu Hamil terkonfirmasi menderita malaria pada saat masuk rumah sakit untuk bersalin. 60% P. falciparum, 32% P.vivax, 4.5% Mixed, 3.5% Lainnya Hanya 30% di antaranya yang disertai demam/gejala klinis

4. Kematian Perinatal Ibu dengan Pf : OR = 2.9 [95%CI: 1.9-4.2], p<0.0001

3.9% (32/808) menunjukkan tanda-tanda malaria berat

Anemia berat : OR=2.6 [95%CI,1.7-3.8], p<0.0001

Satu kematian ibu : P.vivax dengan sepsis bakterial berat 2. Anemia pada Ibu Bersalin yang berhubungan dengan Malaria

5. Kelahiran Prematur Ibu dengan Malaria : OR= 1.5 [(95%CI, 1.2-1.9), p=0.001]

Maternal Pf : Hb Drop of 1.2 g/dl; Anemia Berat :OR 2.8 [95%CI 2.1-3.7],p<0.0001 Maternal Pv : Hb Drop of 0.50 g/dl; Anemia Sedang :OR 1.5 [95%CI 1.1-2.0],p=0.006

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Status Kesehatan Anak di Daerah Endemik Malaria Kematian neonatal Kematian bayi (per 1000 LH) (per 1000 LH) 24

41

64

Papua Barat

21

36

62

Maluku

25

59

93

Maluku Utara

32

51

74

NTT

31

57

80

Rata-rata Indonesia Timur Nasional



Lancet: Global causes of child deaths – Malaria = 7%

Kematian balita (Per 1000 BLT)

Papua

NTB

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34

72

92

27.8

52.7

77.5

20

34

Data di NTT ?

45 Sumber : SDKI 2007 Sumber : http://www.sciencedirect.com/science/article/pii/S0140673612605601

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Status Derajat Kesehatan Masyarakat di NTT Angka Kematian

NTT

BAYI/IMR (Per 1000 LH) IBU/MMR (Per 100.000 LH) BALITA (Per 1000 LH) PREVALENSI GIZI Gizi Buruk Gizi Kurang Gizi Baik Gizi Lebih Umur Harapan Hidup Laki-Laki Perempuan L/P


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Situasi Malaria di NTT Annual Parasite Incidence (2007-2011)

INDONESIA 57 306 80

34 228 44

9,4% 24,2% 64,4% 2,0%

5.40% 13.40% 77.20% 4.30%

62,9 THN 67,2 THN 65,1 THN

70,5 THN

40

30

20

10

0

2007 32

API

2008 28

2009 31

2010 29

2011 26

Source: Profile Kesehatan NTT Tahun 2009 Source: Data Program Malaria, DINKES NTT

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Situasi Malaria di NTT - 2011 API BY DISTRCITS IN NTT - 2011 200

Demographic profile

187

Malaria Profile - 2011

API (0/00) POPULATION 4,694,269

180 160

Clinical Cases 99,375 Malaria Tested 470,800 Confirmed 121,599

140

Babies

Mal + 115,357 5,336 Pregnant Women 126,941 3,704

120 100

API 46.3 29.2

AMI 21.17

API 25.90

78

80

Confirmed Malaria Cases by Age Groups

67

60

45 36

40

32

32

10 - 14 Yo 12%

28

25

23

20

19

16

20

16

14

13

9

6

3

3

2

5-9 Yo 16%

Other 50%

-

Preg Women 3% Unkown 2%

1-4 Yo 18% Babies 4%


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Malaria Program Performances (Lab) - 2011 Clinical Cases 99,375

= 45 % of Total Malaria Cases (Clinical + Confirmed)

Malaria Tested 470,800

Lab

RDT

365,494 78%

105,306 22%

Microscopy Quality % 85.08 77.33 22.93

API and Error Rate Microscopy 200.00

API

150.00

R² = 0.7742

100.00 50.00 API

Linear (API)

0.00

10.00

20.00

30.00 Error rate (%)

40.00

50.00

4.39 18.00 15.86 11.74 45.00 3.05 1.96 100.00


Malaria Program Performances (Treatment & Protection) - 2011 POPULATION 4,694,269

ABER = 10%

Sensitivity Spesifity Error Rate

5,336 21,884 19,287 14,278 54,723 3,704 2,387 121,599


60.00

Range 50 - 100 % 58 - 100 % 2.6 - 48%

Confirmed 121,599

API 25.90

Malaria Tested 470,800

Confirmed 121,599

ACT TREATMENT RATE

API 25.90 SPR

API and Error Rate Microscopy District Lembata Sikka Nagekeo Ende Belu Average Prov Sumba Barat TTU Kota Manggarai

API 187.49 67.38 35.66 31.97 27.84 25.90 19.63 6.04 2.91 1.74

ERROR RATE 48.19 37.78 12.26 21.72 21.23 22.93 11.43 3.33 2.63 8.70

Note: Crosscheck data is not completed yet. Source: Dinkes NTT, April 2012

Type of Parasites

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Babies 1-4 Yo 5-9 Yo 10 - 14 Yo > 15 Yo Preg Women Unkown TOTAL

> 15 Yo 45%

126,941 94,888 3,704

60,211

49.52 %

54,247 31

44.61 % 0.03%

Po

-

-

Mix

7,110

Total

121,599

25.83 % Pf

55.36

5.85 % 100.00

Total

BEDNET

MALARIA SCREENING FOR PREGNANT WOMEN

Pregnant Women Mal Screening Mal Positive

Pf Pv Pm

75% 4%

69,503 57.16 %

Routine ANC Pregnant Women FIC Campaign 5 Yo Children Rep women + Mal Total

67,371 39,371 33,444 32,180 8,382 180,748

37.27 21.78 18.50 17.80 4.64 100

Preg Wmen Babies

126,941 115,357

Bednet 106,742 33,444

Percent 84% 29%

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Environmental factors

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Kenapa Faktor lingkungan?

Malaria transmission cannot be separated from dynamic interaction between the classical triad of host, agent and environment, the three major components of this disease (Aron & Patz, 2001).


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Theory Blum  Status Kesehatan

Perilaku nyamuk

Theory Blum (1974)

mating - host seeking - blood feeding – resting - ovipositing

Derajat kesehatan masyarakat dipengaruhi oleh 4 faktor yaitu :

Udara - Cuaca

1.Lingkungan, 2. Perilaku, 3. Pelayanan kesehatan, dan 4. Keturunan

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Kata Malaria berasal dari bahasa Itali: - mal (=bad) dan - aria (=air) - Menjelaskan bahwa sakit malaria disebabkan oleh “miasma” yang berasal dari rawa-rawa di sekitar Roma. - Juga sering dikenal dengan “jungle fever, marsh fever, paludal fever, or swamp fever”.



Air Jenis-jenis tempat perindukan

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Telur

Jentik saat istirahat di air Jentik yang sudah mau jadi nyamuk

5-7 hari jentik jadi nyamuk

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Nyamuk malaria aktif mencari darah sejak matahari terbenam hingga matahari terbit

•

•



Satu sporozoite bisa menginfeksi host vertebrata. 10 sporozoites dari P. vivax bisa 100% menyebabkan malaria pada manusia

Infective

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Hubungan Causal Penyakit

Mengapa Eco-epidemiology?

Traditional Epidemiological Framework

Ecological - Epidemiological Framework

Agent

Social SYSTEMS

Host

Environment

Ecological

Global

Epidemics

Disease

Paul R. Epstein, M.D., M.P.H. http://med.harvard.edu/chge 1st Lunch Seminar of IRGSC – Kupang, 24 August 2012. Website: http://www.sustainability-k-governance.net/index.html

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Proses evolusi modern epidemiology  Eco-epidemiology

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Eco-epidemiology Concept Konsep eco-epidemiology malaria di proposed pertama kali oleh Bruce-Chwatt (Gilles, 1993) dan kemudian mulai dikembangkan oleh World Health Organization (WHO, 2006a). Epidemiology is “the study of the distribution and determinants of healthrelated states and events and the application of this study to control of health problems” (Last, 1996, p. 1099)

Source : Susser & Susser, (1996a, p. 676) 1st Lunch Seminar of IRGSC – Kupang, 24 August 2012. Website: http://www.sustainability-k-governance.net/index.html

Eco-epidemiology is defined as the “study of ecological influences on human health”. It is also defined as a “Conceptual approach combining molecular, societal, and population-based aspects to study a health-related problem” (Medical Dictionary, 2009).


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Beberapa Konsep Eco-epidemiology malaria 1. Lancet: presented a systematic review of reducing the burden of malaria in different ecological settings from the past to the present emphasising that a sustainable strategy for malaria control approach, with respect to different ecological settings: 1) malaria of deep forest, forest fringe and hills; 2) rural malaria attributable to water resources development and management; 3) rural malaria attributable to wetlands, rivers, streams, coast and nonagricultural man-made habitats; 4) urban and peri-urban malaria. (Keiser, et al, 2005) 2. In Venezuela, Morales (2006) highlighted the importance of eco-epidemiology as a new vision and discipline in fighting and preventing diseases including malaria, and its use in current public health policy.

Beberapa contoh pendekatan ecoepidemiolagy malaria di Indonesia

Species Sanitation

3. In India, the National Institute of Malaria Research (NIMR), through the integrated disease vector project, also used the eco-epidemiological settings to study malaria and its control with respect to different ecotypes and malaria epidemiology (NIMR, 2007) Source: Takken, et al. (1990)


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Variable Eco-epidemiological sebagai faktor risiko malaria yang diteliti

Konsep Eco-epidemiological model dalam penelitian 1st Lunch Seminar of IRGSC – Kupang, 24 August 2012. Website: http://www.sustainability-k-governance.net/index.html

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Study Areas



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Research Q 1


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Significant results

Research Q 2 - 3

Belu memiliki kasus malaria tertinggi dibanding kab/kota lain di Timor Barat

Matrix of the mean differences of the average AMI (logarithmic transformed ) by districts in West Timor 2003–2006


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T-test result for mean difference of average AMI (logarithmic transformed) between villages located on the districts boundary and non-boundaries of West Timor

Kasus malaria lebih tinggi pada desa-desa yang terletak pada “zona perbatasan”

ANOVA results investigating differences in average AMI (log-transformed) by topographic settings in West Timor

Semakin tinggi altititude semakin rendah kasus malaria

Spatial distribution of average malaria cases (2003-2006) boundary villages on the districts’ boundary in West Timor

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Average malaria incidence (2003-2006) by altitude in West Timor

Lunch Seminar of IRGSC – Kupang, 24 August 2012. Website: http://www.sustainability-k-governance.net/index.html

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1st


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Cuaca VS Malaria The correlation results between the population density and the average monthly malaria incidence in West Timor, 2003–2006

Pearson correlation result for rainfall and monthly malaria incidence in nine villages of West Timor, 2003–2006

Pearson correlation result for temperature, relative humidity, wind speed and monthly malaria incidence in Lasiana Village of West Timor, 2003–2006

Semakin tinggi kepadatan penduduk semakin rendah kasus malaria Malaria spatial distribution based on population density by villages in West Timor


Kasus malaria dipengaruhi oleh jumah hari hujan, suhu dan kelembaban Pada musim kering, jumlah desa yang berisiko tinggi malaria lebih banyak dibanding pada musim hujan 1st Lunch Seminar of IRGSC – Kupang, 24 August 2012. Website: http://www.sustainability-k-governance.net/index.html

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Entomology survey sites – West Timor


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Survey entomology di West Timor

Average local weather condition in West Timor during entomological survey

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A schematic topographical feature of malaria vectors distribution in West Timor



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25

70

20

60

Landing Rate (per hour)


1st


1st

15 10

5

50 40 30 20 10

0 1800-

1900-

2000-

2100-

2200-

2300-

2400-

0100-

0200-

0300-

0400-

0500-

1900

2000

2100

2200

2300

2400

0100

0200

0300

0400

0500

0600

0 1800- 1900- 2000- 2100- 2200- 2300- 2400- 0100- 0200- 0300- 0400- 05001900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500 0600

Time of Night

Time of Night

The linear fitted model for An. aconitus host seeking activities

The 2O polynomial curve fitted model for An. barbirostris host seeking activities 25



120 100 80 60 40 20

20 15 10 5 0

0 1800-

1900-

2000-

2100-

2200-

2300-

2400-

0100-

0200-

0300-

0400-

0500-

1900

2000

2100

2200

2300

2400

0100

0200

0300

0400

0500

0600

1800-

1900-

2000-

2100-

2200-

1900

2000

2100

2200

2300

The 3O polynomial curve fitted model for An. subpictus host seeking activities


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2300-

2400-

0100-

0200-

0300-

0400-

0500-

2400

0100

0200

0300

0400

0500

0600

Time of Night

Time of Night

2O

The polynomial curve fitted model for An. vagus host seeking activities in West Timor


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Beberapa faktor manusia yang berkorelasi nyata dengan kejadian malaria

Types of potential mosquito breeding places in research areas Mangrove (a), creek (b), animal hoof prints (c1-c4), stagnant water in the river (d) and rice field with algae



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Beberapa hasil significant dan rekomendasi

Vector malaria yang significant di Timor Barat dan rekomendasi intervensi


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Recommendations for Future Malaria Control 1. Penularan malaria bersifat lokal spesifik, karena itu pendekatan ekoepidemiologis sangat membantu dalam penentuan strategi dan priorisasi program intervention dengan melihat berbagai faktor ekologis 2. Penggunaan teknologi GIS – pemahaman tentang faktor cuaca – perilaku vektor – perilaku manusia di daerah malaria sangat bermanfaat dalam proses pengambilan keputusan berbasis bukti untuk program malaria 3. Untuk konteks West Timor, prioritas program malaria terutama pada daerah pesisir dan desa-desa pada “zona perbatasan” . 4. Kelompok rentan seperti Ibu hamil dan Balita harus mendapat perhatian dalam program pencegahan dan penanggulangan malaria. 5. Di West Timor Anopheles species umumnya “feed and rest indoors”. Karena itu program pemberantasan nyamuk yang effektif adalah kelambu dan tidak anjurkan untuk IRS. 6. Penguatan quality assurance dalam progam malaria: logistik + lab 1st Lunch Seminar of IRGSC – Kupang, 24 August 2012. Website: http://www.sustainability-k-governance.net/index.html

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Beberapa publikasi malaria 1.

Relationships between anopheline mosquitoes and topography in West Timor and Java, Indonesia. Ermi Ndoen, Clyde Wild, Pat Dale, Neil Sipe, Mike Dale. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2939620/

2.

DUSK TO DAWN ACTIVITY PATTERNS OF ANOPHELINE MOSQUITOES IN WEST TIMOR AND JAVA, INDONESIA. Ermi Ndoen, Clyde Wild, Pat Dale, Neil Sipe and Mike. http://www.tm.mahidol.ac.th/seameo/2011-42-3/09-4743.pdf

3.

Mosquito Longevity, Vector Capacity, and Malaria Incidence in West Timor and Central Java, Indonesia. Ermi Ndoen, Clyde Wild, Pat Dale, Neil Sipe, Mike Dale. http://www.isrn.com/journals/ph/2012/143863/

4.

MALARIA IN INDONESIA: A SUMMARY OF RECENT RESEARCH INTO ITS ENVIRONMENTAL RELATIONSHIPS. Pat Dale, Neil Sipe, Sugi Anto, Bangkit Hutajulu, Ermi Ndoen, Meisy Papayungan, et al. http://www.tm.mahidol.ac.th/seameo/2005_36_1/01-3358.pdf

5.

A novel approach for modeling malaria incidence using complex categorical household data: The minimum message length (MML) method applied to Indonesian data. Gerhard Visser, Pat Dale, David Dowe, Ermi Ndoen, Mike Dale, Neil Sipe. Computational Ecology and Software, 2012, 2(3):140-159. http://www.iaees.org/publications/journals/ces/articles/2012-2(3)/a-novel-approach-for-modelingmalaria-incidence.pdf


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Pencegahan Anti malarial drug Desmond Tutu Archbishop Emeritus

Kelambu Repellent Kawat nyamuk

ACT SP Quinine Primaquine

“…We have the means. We often lack the political will. Let us reverse this trend and make our world malaria free” http://www.mobilising4malaria.org/pages/en/quotes_and_statements.html#tutu

Vector Control + Modifikasi Lingkungan

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Environmental factors and an eco-epidemiological model of malaria in Indonesia

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