KUESIONER SURVEY PENGGUNAAN KELAMBU

LAMPIRAN

93

Lampiran 1 Kuesioner Survey Penggunaan Kelambu

KUESIONER SURVEY PENGGUNAAN KELAMBU

Kecamatan

: …………………………………………………………

Wilayah kerja Puskesmas

: …………………………………………………………

Wilayah kerja Pustu

: …………………………………………………………

Nama Enumerator

: …………………………………………………………

Tanggal Wawancara

: …………………………………………………………

94

1.

Nama Responden

: .........................................................

2.

Nama Kepala Keluarga

: ........................................................

3.

Alamat

4.

No. Rumah, RT/RW

:

Dusun

:

Desa/Kelurahan

:

Kecamatan

:

Nama Posyandu terdekat

:

Informed consent Saya .............................. dari ........................ Kami sedang melakukan survey mengenai pemakaian kelambu untuk memproteksi nyamuk malaria di Kabupaten Bangka. Kami sangat mengharapkan partisipasi Bapak/Ibu dalam survey ini. Informasi yang Bapak/Ibu berikan akan membantu pemerintah dalam upaya penanggulangan malaria di daerah ini. Survey ini akan memakan waktu tidak lebih

dari

30

menit.

Informasi

yang

Bapak/Ibu

berikan

akan

dijaga

kerahasiaannya. Keikutsertaan dalam survey ini bersifat sukarela, tetapi kami sangat berharap Bapak/Ibu dapat berpartisipasi karena informasi yang Bapak/Ibu berikan sangat berharga. Apakah ada yang ingin ditanyakan berkenaan dengan survey ini? Apakah saya dapat mulai mewawancara Bapak/Ibu sekarang?

Tanda tangan pewawancara: ____________

Tanggal:______________

Responden setuju untuk diwawancara?  Ya  Wawancara dilanjutkan  Tidak  Akhiri wawancara

DAFTAR ANGGOTA KELUARGA

95

Kami ingin mendapatkan informasi mengenai anggota keluarga dan orang-orang yang tinggal di rumah ini. No.

(5) 01 02 03 04 05 06 07 08 09 10

Nama anggota keluarga dan tamu

Hubungan dengan kepala keluarga*)

Sebutkan nama semua anggota keluarga yang tinggal di rumah ini termasuk pemondok dan tamu yang menginap di sini tadi malam. Dimulai dengan nama kepala keluarga

Sebutkan hubungan (nama) dengan kepala keluarga*)

(6)

(7)

Gender

Umur

Pekerjaan

Status kehamilan

Nomor Kehamil an

Apakah jenis kelaminnya (nama) (laki-laki atau perempuan) ?

Berapa usia (nama)? (dalam tahun)

Apa pekerjaan (nama) **)

Untuk wanita dewasa, apakah saat ini (nama) sedang hamil?

Jika sedang hamil, saat ini kehamilan keberapa?

(8)

(9)

(10)

(11)

(12)

L

P

1

2

L

P

1

2

L

P

1

2

L

P

1

2

L

P

1

2

L

P

1

2

L

P

1

2

L

P

1

2

L

P

1

2

L

P

1

2

ya 1 ya 1 ya 1 ya 1 ya 1 ya 1 ya 1 ya 1 ya 1 ya 1

tdk/ tdk tahu 2 tdk/ tdk tahu 2 tdk/ tdk tahu 2 tdk/ tdk tahu 2 tdk/ tdk tahu 2 tdk/ tdk tahu 2 tdk/ tdk tahu 2 tdk/ tdk tahu 2 tdk/ tdk tahu 2 tdk/ tdk tahu 2

*) Kode untuk hubungan dengan kepala keluarga (pertanyaan nomor 7): Hubungan dengan kepala keluarga:

Status tinggal

Apakah (nama) penghuni tetap di rumah ini?

Apakah (nama) tinggal di sini malam tadi

(13)

(14)

ya tidak

ya tidak

1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

ya tidak 1

2

96

01 : Kepala keluarga 02 : Istri 03 : Anak 04 : Cucu

05 06 07 08

: Orang tua/mertua : Adik/kakak : Paman/bibi : Keponakan

09 10 11 12

: Nenek/kakek : Saudara : Pembantu RT : Lainnya (sebutkan)

**) Kode untuk pekerjaan (pertanyaan no. 10) 01. PNS 02. Pekerja timah 03. Petani 04. Nelayan

tambang

05. Pedagang/wiraswasta 06. Satpam/penjaga malam

09. TNI/Polisi 10. Pegawai Swasta

07. Buruh harian 08. Sopir

11. Ibu rumah tangga 12. Lain-lain

Untuk meyakinkan bahwa semua anggota keluarga sudah didaftarkan: 1. Apakah ada anggota keluarga lain seperti anak kecil atau bayi yang belum terdaftarkan? 2. Apakah ada orang lain yang bukan anggota keluarga, seperti pembantu rumah tangga, pemondok atau teman yang juga biasa tinggal disini yang belum terdaftarkan? 3. Apakah ada tamu atau orang-orang yang kadang-kadang berkunjung ke tempat anda dan menginap malam tadi yang belum terdaftarkan? Apakah menggunakan lembar tambahan untuk mendaftarkan anggota keluarga:  Ya, nomor tabel : ...........  Tidak

No . 15

16

Pertanyaan Apakah di rumah anda terdapat kelambu yang berinsektisida? Berapa banyak kelambu berinsektisida yang anda punyai?

17

Apakah merek kelambu berinsektisida tersebut?

18

Kapankah anda memperoleh kelambu berinsektisida tersebut?

19

Apakah kelambu

Kode kategori  

Ya tidak

Skip  37

.................. Kelambu #1  Olyset  Permanet  Lainnya ....... ....................  < 3 bulan yang lalu  3 bulan – < 1 tahun yang lalu  1 - 3 tahun yang lalu  >3 th yang lalu  Ya

Kelambu #2  Olyset  Permanet  Lainnya ....... ....................  < 3 bulan yang lalu  3 bulan – < 1 tahun yang lalu  1 - 3 tahun yang lalu  >3 th yang lalu  Ya

Kelambu #3  Olyset  Permanet  Lainnya ....... ....................  < 3 bulan yang lalu  3 bulan – < 1 tahun yang lalu  1 - 3 tahun yang lalu  >3 th yang lalu  Ya

97

berinsektisida tersebut anda pakai ketika tidur?

20

Jika tidak dipakai, apa alasannya?

 

 

  

Kadang 21 - kadang tidak Takut insektisida yang ada di kelambu Panas Telah menggunakan alat proteksi nyamuk lain Sulit memasangnya Sebagai cadangan Lainnya

.......................... (Langsung ke 17 untuk kelambu #2) 21

Kapankah anda mulai memakai kelambu berinsektisida tersebut?

      

22

Sejak anda menggunakan kelambu berinsektisida, pernahkah anda mencucinya?

23

Apakah anda mencucinya secara rutin?

  

24

Bagaimana jadwal pencuciannya?



25

Kapan anda terakhir mencuci kelambu yang dipakai?

26

Apa yang anda lakukan setelah mencuci kelambu?

< 3 bulan yang lalu 3 bulan – < 1 tahun yang lalu 1 - 3 tahun yang lalu >3 th yang lalu Ya Tidak pernah Tidak tahu

(langsung ke 27)

Ya Tidak Tidak tahu

(langsung ke 25)

>1x dlm 3 bulan  1x dalam 3 bulan  1 x dalam >3 – 6 bulan  1 x dalam waktu >6 bulan  < 1 bulan yang lalu  1 – 3 bulan yang lalu  >3 bulan yang lalu  Tidak pernah  Dipanaskan dengan cara memasukkan kelambu ke dalam plastik

 

 

  

Kadang 21 - kadang tidak Takut insektisida yang ada di kelambu Panas Telah menggunakan alat proteksi nyamuk lain Sulit memasangnya Sebagai cadangan Lainnya

.......................... (Langsung ke 17 untuk kelambu #3)       

< 3 bulan yang lalu 3 bulan – < 1 tahun yang lalu 1 - 3 tahun yang lalu >3 th yang lalu Ya Tidak pernah Tidak tahu

(langsung ke 27)

  

Ya Tidak Tidak tahu

(langsung ke 25)



>1x dlm 3 bulan  1x dalam 3 bulan  1 x dalam >3 – 6 bulan  1 x dalam waktu >6 bulan  < 1 bulan yang lalu  1 – 3 bulan yang lalu  >3 bulan yang lalu  Tidak pernah  Dipanaskan dengan cara memasukkan kelambu ke dalam plastik hitam dan

Kadang 21 - kadang  tidak  Takut insektisida yang ada di kelambu  Panas  Telah menggunakan alat proteksi nyamuk lain  Sulit memasangnya  Sebagai cadangan  Lainnya ........................ (Langsung ke 17 untuk kelambu yang lain atau jika tidak ada, langsung ke 38)  < 3 bulan yang lalu  3 bulan – < 1 tahun yang lalu  1 - 3 tahun yang lalu  >3 th yang lalu  Ya  Tidak pernah  Tidak tahu (langsung ke 27)

  

Ya Tidak Tidak tahu

(langsung ke 25)



>1x dlm 3 bulan  1x dalam 3 bulan  1 x dalam >3 – 6 bulan  1 x dalam waktu >6 bulan  < 1 bulan yang lalu  1 – 3 bulan yang lalu  >3 bulan yang lalu  Tidak pernah  Dipanaskan dengan cara memasukkan kelambu ke dalam plastik

98

hitam dan menjemurnya  Dijemur biasa  Diangin-angin  Lainnya........... ....................... .......................

(langsung ke 28 untuk daerah perlakuan* atau ke32 untuk yang lainnya)

27

Jika anda tidak mencuci kelambu, apa alasannya?

menjemurnya  Dijemur biasa  Diangin-angin  Lainnya........... ....................... ....................... (langsung ke 28 untuk daerah perlakuan* atau ke-32 untuk yang lainnya)

hitam dan menjemurnya  Dijemur biasa  Diangin-angin  Lainnya........... ....................... .......................

(langsung ke 28 untuk daerah perlakuan* atau ke32 untuk yang lainnya)

 Takut insektisida di kelambu hilang  Takut meracuni ikan/makhluk lain di kolam/perairan umum  Tidak tahu  Lupa  Tidak sempat/enggan  Lainnya..................... .......................

 Takut insektisida di kelambu hilang  Takut meracuni ikan/makhluk lain di kolam/perairan umum  Tidak tahu  Lupa  Tidak sempat/enggan  Lainnya...................... ......................

 Takut insektisida di kelambu hilang  Takut meracuni ikan/makhluk lain di kolam/perairan umum  Tidak tahu  Lupa  Tidak sempat/enggan  Lainnya..................... .......................

(langsung ke 32)

(langsung ke 32)

(langsung ke 32)

Pertanyaan no. 28 – 31 khusus untuk daerah perlakuan: Gunung Muda, Sungai Liat, Sinar Baru, Bakam, Puding Besar dan Petaling

28

29

30

Apakah dilakukan pemanasan (heat regeneration: yaitu memasukkannya ke dalam plastik hitam dan menjemurnya di panas mata hari) terhadap kelambu setelah dicuci? Jika ya, apakah dilakukan secara rutin pada setiap mencuci kelambu? Kapankah waktu terakhir kali dilakukan pemanasan (heat regeneration) terhadap kelambu yang digunakan?

31

Jika tidak pernah melakukan pemanasan terhadap kelambu setelah dicuci, apa alasannya?

32

Apakah ada yang tidur memakai kelambu tadi malam?

   

Ya Kadangkadang Tidak pernah Tidak tahu

   

Ya Kadangkadang Tidak pernah Tidak tahu

   

Ya Kadangkadang Tidak pernah Tidak tahu

31 31    

   

31    

Ya Tidak Tidak tahu < 1 bulan yang lalu  1 – 3 bulan yang lalu  >3 bulan yang lalu  Tidak pernah (Langsung ke 32)  Tidak praktis  Tidak tahu  Tidak mau/enggan  Lainnya……… ………………  Ya  Tidak  Tidak tahu

Ya Tidak Tidak tahu < 1 bulan yang lalu  1 – 3 bulan yang lalu  >3 bulan yang lalu  Tidak pernah (Langsung ke 32)  Tidak praktis  Tidak tahu  Tidak mau/enggan  Lainnya……… ………………  Ya  Tidak  Tidak tahu

Ya Tidak Tidak tahu < 1 bulan yang lalu  1 – 3 bulan yang lalu  >3 bulan yang lalu  Tidak pernah (Langsung ke 32)  Tidak praktis  Tidak tahu  Tidak mau/enggan  Lainnya……… ………………  Ya  Tidak  Tidak tahu

(langsung ke 34)

(langsung ke 34)

(langsung ke 34)

99

33

Siapa yang tidur memakai kelambu tadi malam?

Nama ________

Nama ________

Nama ________

No.

No.

No.

Nama ________

Nama ________

No.

No.

Nama ________

Nama ________

No.

No.

Nama ________

Nama ________

No.

No.

Nama ________ No.

Nama ________ No.

Nama ________ No.

34

Mintalah responden untuk memperlihatkan kepada anda kelambu yang mereka pakai. Jika lebih dari 3 buah, gunakan kuesioner tambahan.

35

Perhatikan cara memasang kelambu yang dilakukan

Nama ________

Nama ________

No.

No.

Kembali ke 16 untuk kelambu berikutnya, atau jika tidak ada kelambu lain lanjutkan ke 34

Kembali ke 16 untuk kelambu berikutnya, atau jika tidak ada kelambu lain lanjutkan ke 34

 





 

36

Bagaimana kondisi kelambu tersebut?

 

No

Pertanyaan

Diamati Tidak diamati

Menutupi seluruh bagian tempat tidur Terdapat bagian yang memungkinkan nyamuk masuk Tidak dipasang Lainnya, .................... .................... .................... Tidak ada lubang Terdapat lubang

 





 

 

Nama ________ No.

Diamati Tidak diamati

Menutupi seluruh bagian tempat tidur Terdapat bagian yang memungkinkan nyamuk masuk Tidak dipasang Lainnya, .................... .................... .................... Tidak ada lubang Terdapat lubang

Kode kategori

Kembali ke 16 kolom pertama pada kuesioner yang baru, atau jika tidak ada kelambu lain lanjutkan ke 34  Diamati  Tidak diamati





 

 

Menutupi seluruh bagian tempat tidur Terdapat bagian yang memungkinkan nyamuk masuk Tidak dipasang Lainnya, .................... .................... .................... Tidak ada lubang Terdapat lubang

Skip

100

. 37

38

39

40

(Khusus untuk yang tidak memiliki kelambu berinsektisida) Mengapa anda tidak memiliki kelambu berinsektisida? Apakah dilakukan penyemprotan pada rumah dan lingkungan anda dalam kurun maksimal 1 tahun ini? Berapa bulan yang lalu penyemprotan terakhir dilakukan? Siapa yang melakukan penyemprotan?

41

Sebutkan alat pencegah nyamuk lain selain kelambu yang anda gunakan

42

Sebutkan alat pencegah nyamuk lain selain kelambu yang anda gunakan pada malam tadi

43

Apakah anda menggunakannya secara rutin setiap malam? Bagaimana kondisi geografis lokasi tempat tinggalnya?

44

45

46

Apakah di sekitar rumah terdapat: a. Tambang/bekas tambang b. Sawah c. Kebun d. Kolam e. Semak-semak f. Kandang Luas rumah:

      

Diberikan kepada orang lain Tidak memperolehnya, baik dari puskesmas, bidan maupun posyandu Sudah rusak Lain-lain, sebutkan............................ Ya Tidak Tidak tahu

............... bulan yang lalu                           

Pemerintah (Dinas Kesehatan) Perusahaan swasta LSM Swadaya masyarakat Anggota keluarga Lainnya, ...................................... Tidak tahu Anti nyamuk bakar Insektisida aerosol Anti nyamuk elektrik Insektisida lotion Lainnya,....................................... Tidak ada Anti nyamuk bakar Insektisida aerosol Anti nyamuk elektrik Insektisida lotion Lainnya,....................................... Tidak ada Ya Tidak Tidak tahu Daerah pegunungan Daerah pantai Daerah rawa Daerah dataran rendah Lainnya,............................

a. b. c. d. e. f.

Tambang/bekas tambang Sawah Kebun Kolam/kolam mata air Semak-semak Kandang

............................m 47

Bahan dinding rumah:

41

   

Tembok Papan Bilik bambu Batu

2

 44

Ya 1 1 1 1 1 1

dk 2 2 2 2 2 2

101

48

Warna cat dinding rumah

49

Apakah ventilasi rumah dilengkapi kasa nyamuk?

50

Apakah ada anggota keluarga yang tinggal di rumah ini yang melakukan aktifitas malam hari di luar rumah? Jika ya, siapa saja anggota keluarga yang melakukan aktifitas malam hari di luar rumah?

51

 

Dilapisi wall paper Lainnya ...........................

     

Warna gelap Warna terang Bermotif/bergambar Tidak dicat Ya Tidak

  

Ya Tidak Tidak tahu

52

Nama & no. aktifitas**)

Jenis

Nama _______ No.

Jenis aktifitas: 01 Bekerja 02 Jalanjalan/bermain 03 Ronda malam 04 Lain-lain (sebutkan)

Nama ________ No.

Nama ________ No.

Nama ________ No.

Nama ________ No. 52

Fasilitas kesehatan yang biasa dikunjungi

53

Apakah ada anggota keluarga yang tinggal di rumah ini yang menderita malaria dalam tiga bulan terakhir ini? Sebutkan nama orang yang menderita malaria tersebut dan siapa yang melakukan diagnosa**)

54

**) Yang melakukan diagnosa malaria: 01 Dokter

     

Puskesmas Pustu Praktek dokter Klinik Mantri Polindes  Lain2............................  Ya  Tidak  Tidak tahu

Nama & no. Nama _______ No.

Nama ________ No.

Yg mendiagnosa**)

55

102

02 03 04 05 06

Bidan Perawat Perkiraan sendiri Lainnya (disebutkan) Tidak tahu

Nama ________ No.

Nama ________ No.

55

Menurut anda apa yang menyebabkan malaria?

  

Gigitan nyamuk malaria Gigitan nyamuk Tidak tahu

56

Kapan nyamuk malaria berkeliaran dan menggigit manusia?

57

Dimana nyamuk berkembang biak?

      

Malam hari Sepanjang hari Siang hari Tidak tahu Pada air yang menggenang Di kebun/semak-semak/hutan Tidak tahu

58

Apa yang anda lakukan untuk mencegah malaria? a. Menggunakan kelambu b. Menggunakan alat proteksi nyamuk lain selain kelambu (obat anti nyamuk bakar, aerosol, dll) c. Memasang kipas angin d. Tidak melakukan apa-apa Menurut anda, apa kegunaan memakai kelambu berinsektisida: a. Mencegah kontak dengan nyamuk, kutu atau serangga lainnya b. Insektisidanya dapat membunuh nyamuk, kutu atau serangga lainnya c. Tidak tahu

59

malaria

a. b. c. d.

a.

b.

c.

Ya Menggunakan kelambu 1 Menggunakan alat proteksi 1 nyamuk lain selain kelambu 1 Memasang kipas angin 1 Tidak melakukan apa-apa 1

Mencegah kontak dengan nyamuk, kutu atau serangga lainnya Insektisidanya dapat membunuh nyamuk, kutu atau serangga lainnya Tidak tahu

Tdk 2 2 2 2 2

Ya 1

Tidak 2

1

2

1

2

103

Lampiran 2 Kuesioner Kajian Kasus Kontrol Berpadanan

KUESIONER STUDI KASUS KONTROL EFIKASI PROTEKSI KELAMBU OLYSET DI KABUPATEN BANGKA

Kecamatan

: …………………………………………………………

Wilayah kerja Puskesmas

: …………………………………………………………

Wilayah kerja Pustu

: …………………………………………………………

Nama Enumerator

: …………………………………………………………

Tanggal Wawancara

: …………………………………………………………

Tanggal Kunjungan

: …………………………………………………………

104

1. Nama responden

: ............................................................

2. Hubungan dengan anak

:

*) Kode untuk hubungan dengan anak (pertanyaan nomor 2): Hubungan dengan anak: 01 : Ibu 02 : Ayah 03 : Kakak 04 : Bibi/paman/ua

05 06 07 08

: Nenek : Kakek : Pembantu RT : Lainnya (sebutkan)

3. Nama Anak

: ............................................................

4. Jenis kelamin

: L / P*)

5. Tanggal lahir (umur)

: ............................................................

6. Nama Kepala Keluarga

: ............................................................

7. Alamat a. No. Rumah, RT/RW

:

b. Dusun

:

c. Desa/Kelurahan

:

d. Kecamatan

:

e. Rincian GPS

:

8. Nama Posyandu terdekat

: Informed Consent

Saya .............................. dari ........................ Kami sedang melakukan survey mengenai pemakaian kelambu untuk memproteksi nyamuk malaria di Kabupaten Bangka. Kami sangat mengharapkan partisipasi Bapak/Ibu dalam survey ini. Informasi yang Bapak/Ibu berikan akan membantu pemerintah dalam upaya penanggulangan malaria di daerah ini. Survey ini akan memakan waktu tidak lebih dari 30 menit. Informasi yang Bapak/Ibu berikan akan dijaga kerahasiaannya. Keikutsertaan dalam survey ini bersifat sukarela, tetapi kami sangat berharap Bapak/Ibu dapat berpartisipasi karena informasi yang Bapak/Ibu berikan sangat berharga. Apakah ada yang ingin ditanyakan berkenaan dengan survey ini? Apakah saya dapat mulai mewawancara Bapak/Ibu sekarang? Tanda tangan pewawancara: ____________ Responden setuju untuk diwawancara? Ya  Wawancara dilanjutkan

Tanggal:______________

105

 Tidak  Akhiri wawancara

No. 1

Pertanyaan

Kode kategori

Apakah di rumah anak ini terdapat kelambu berinsektisida?

Ya Tidak

2

Jika ya, apakah merek kelambu berinsektisida tersebut?

3

Dari mana kelambu yang dipakai diperoleh?

4

Apakah anak ini tidur menggunakan kelambu berinsektisida?

Olyset Permanet Lainnya ....... .................... Puskesmas Pustu Bidan Posyandu Lainnya,............. Ya Kadang-kadang Tidak Tidak tahu

5

6

7

8

9

10

11

12

13

Kapankah anak ini mulai memakai kelambu tersebut? (langsung ke 7) Jika anak tidak tidur memakai kelambu berinsektisida, apa alasannya?

Sejak kelambu digunakan, kelambu tersebut dicuci?

pernahkah

Jika ya, apakah kelambu dicuci secara rutin?

Bagaimana jadwal pencuciannya?

Kapan kelambu yang digunakan terakhir dicuci?

(langsung ke 12) Jika kelambu tidak pernah alasannya?

dicuci,

apa

Apakah dilakukan pemanasan (heat regeneration: yaitu memasukkannya ke dalam plastik hitam dan menjemurnya di panas mata hari) terhadap kelambu setelah dicuci? Jika ya, apakah dilakukan secara rutin pada setiap mencuci kelambu?

Ski p  16

6

< 1 bulan yang lalu 1 – 3 bulan yang lalu >3 bulan yang lalu Takut insektisida yang ada di kelambu Panas Telah menggunakan alat proteksi nyamuk lain Sulit memasangnya Lainnya ............................... Ya Tidak pernah Tidak tahu Ya Tidak Tidak tahu

11

10

>1x dlm 3 bulan 1x dalam 3 bulan 1 x dalam >3 – 6 bulan 1 x dalam waktu >6 bulan < 1 bulan yang lalu 1 – 3 bulan yang lalu >3 bulan yang lalu Tidak pernah Takut insektisida di kelambu hilang Takut meracuni ikan/makhluk lain kolam/perairan umum Tidak tahu Lupa Tidak sempat/enggan Lainnya............................................ Ya Kadang-kadang Tidak pernah Tidak tahu

di

15 Ya Tidak Tidak tahu

106

14

15

16

17

18

Kapankah waktu terakhir kali dilakukan pemanasan (heat regeneration) terhadap kelambu yang digunakan? (langsung ke 17) Jika tidak pernah melakukan pemanasan terhadap kelambu setelah dicuci, apa alasannya? (langsung ke 17) (Khusus untuk yang tidak memiliki kelambu berinsektisida) Mengapa anak ini tidak memiliki kelambu berinsektisida? Apakah dilakukan penyemprotan pada rumah dan lingkungan anda dalam kurun maksimal 1 tahun ini?

< 1 bulan yang lalu 1 – 3 bulan yang lalu >3 bulan yang lalu Tidak pernah Tidak praktis Tidak tahu Tidak mau/enggan Lainnya……………………… Diberikan kepada orang lain Tidak memperolehnya, baik dari puskesmas, bidan maupun posyandu Sudah rusak Lain-lain, sebutkan............................ Ya Tidak Tidak tahu

Berapa bulan yang lalu penyemprotan dinding rumah terakhir dilakukan?

............... bulan yang lalu

19

Siapa yang melakukan penyemprotan?

20

Sebutkan alat pencegah nyamuk lain selain kelambu yang anda gunakan

Pemerintah (Dinas Kesehatan) Perusahaan swasta LSM Swadaya masyarakat Anggota keluarga Lainnya, ...................................... Tidak tahu Anti nyamuk bakar Insektisida aerosol Anti nyamuk elektrik Insektisida lotion Lainnya,................................ Tidak ada

21

Apakah anda menggunakannya secara rutin setiap malam?

Ya Tidak Tidak tahu

22

Bagaimana kondisi geografis lokasi tempat tinggalnya?

Daerah pegunungan Daerah pantai Daerah rawa Daerah dataran rendah Lainnya,............................

23

Apakah di sekitar rumah terdapat: Tambang/bekas tambang Sawah Kebun Kolam Semak-semak Kandang

24

Luas rumah: ............................m

25

Bahan dinding rumah:

26

Warna cat dinding rumah

 22

Ya Tdk Tambang/bekas tambang Sawah Kebun Kolam/kolam mata air Semak-semak Kandang 2

Tembok Papan Bilik bambu Batu Dilapisi wall paper Lainnya ........................... Warna gelap Warna terang Bermotif/bergambar Tidak dicat

1 1 1 1 1 1

20

2 2 2 2 2 2

107

27

Apakah ventilasi rumah dilengkapi kasa nyamuk?

Ya Tidak

28

Apakah anak ini pernah menginap di tempat lain dalam kurun maksimum 1 bulan yang lalu?

Ya Tidak

29

Jika ya, sebutkan dikunjungi

nama

tempat

yang ..................................................................

Pertanyaan no. 30 s.d. 31 untuk yang positif malaria:

anak Plasmodium vivax Plasmodium falciparum Plasmodium ovale Mix Lainnya

30

Apakah jenis plasmodiumnya:

31

Obat yang diberikan dan dosisnya pada saat terserang malaria

.................................................................... . .................................................................... . .................................................................... .

32

Menurut anda malaria?

33

Kapan nyamuk malaria menggigit manusia?

34

Dimana nyamuk malaria berkembang biak?

35

Apa yang anda lakukan untuk mencegah malaria? Menggunakan kelambu Menggunakan alat proteksi nyamuk lain selain kelambu (obat anti nyamuk bakar, aerosol, dll) Memasang kipas angin Tidak melakukan apa-apa Menurut anda, apa kegunaan memakai kelambu berinsektisida: Mencegah kontak dengan nyamuk, kutu atau serangga lainnya Insektisidanya dapat membunuh nyamuk, kutu atau serangga lainnya Tidak tahu

36

37

apa

yang

menyebabkan

berkeliaran

dan

Apakah kegunaan pemanasan (heat regeneration) setelah mencuci kelambu? Mengaktifkan kembali insektisida yang terkandung di dalam benang kelambu Tidak tahu

Gigitan nyamuk malaria Gigitan nyamuk Tidak tahu Malam hari Sepanjang hari Siang hari Tidak tahu Pada air yang menggenang Di kebun/semak-semak/hutan Tidak tahu Ya Tdk Menggunakan kelambu Menggunakan alat proteksi nyamuk lain selain kelambu Memasang kipas angin Tidak melakukan apa-apa

1

2

1 1 1

2 2 2 Ya

Mencegah kontak dengan nyamuk, kutu atau serangga lainnya Insektisidanya dapat membunuh nyamuk, kutu atau serangga lainnya Tidak tahu

Mengaktifkan kembali insektisida yang terkandung di dalam benang kelambu Tidak tahu

1

1

1

Ya 1

1

108

109

Lampiran 3 Program SAS untuk Analisis Data Survey Penggunaan Kelambu

I.

NET USE SURVEY

/***************************************************************** * Program: netuse.sas * Author: * Purpose: * * Inputs: Excel File: E:\NCSU\NETUSE\netsurvey111309 * * Created: Nov 13, 2009 * Revisions I: Dec 21, 2009 *****************************************************************/ * 1 2 3 4 5 6 7 ; *23456789012345678901234567890123456789012345678901234567890123456 7890123456789; OPTIONS MACROGEN SYMBOLGEN NODATE; LIBNAME netuse "E:\NCSU\NETUSE\"; %LET netuse = E:\NCSU\NETUSE\; %MACRO getdata(dataset,sheet,name); PROC IMPORT DATAFILE = "&netuse.&dataset..xls" OUT = &name DBMS = EXCEL REPLACE; SHEET = "&sheet"; GETNAMES=YES; RUN; PROC CONTENTS; RUN; %MEND getdata; %getdata(netsurvey111309,analysisfinal, survey); PROC GENMOD DATA=survey DESCENDING; CLASS ID Prev time; MODEL UseNetWhenSleep=treat prev time/dist=bin link=logit; REPEATED SUBJECT=ID/TYPE=EXCH; RUN; PROC GENMOD DATA=survey DESCENDING; CLASS ID Prev time; MODEL NetWashed=treat prev time/dist=bin link=logit; REPEATED SUBJECT=ID/TYPE=EXCH; RUN; PROC GENMOD DATA=survey DESCENDING; CLASS ID Prev time; MODEL RoutineWashed=treat prev time/dist=bin link=logit; REPEATED SUBJECT=ID/TYPE=EXCH; RUN; PROC SORT DATA=survey; BY ID NumNets; RUN; DATA BednetSum;

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SET survey; BY ID NumNets; RETAIN UseCnt WashCnt RwashCnt HeatCnt RheatCnt; IF FIRST.ID THEN DO; UseCnt=0; WashCnt=0; RwashCnt=0; HeatCnt=0; RheatCnt=0; END; IF UseNetWhenSleep=1 THEN UseCnt + 1; IF NetWashed=1 THEN WashCnt + 1; IF RoutineWashed=1 THEN RwashCnt + 1; IF Heated=1 THEN HeatCnt + 1; IF RoutineHeated=1 THEN RheatCnt + 1; IF Last.ID; *KEEP ID UseCnt WashCnt RwashCnt; LABEL UseCnt="# Nets used in household" WashCnt="# Used nets that are washed in Household" RwashCnt="# Used nets that are washed routine in Household" HeatCnt="# Used nets that are heated in Household" RheatCnt="# Used nets that are washed routine in Household" ; RUN; PROC EXPORT DATA=BednetSum OUTFILE="E:\NCSU\NETUSE\bednet" DBMS=EXCEL; RUN;

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Lampiran 4 Program SAS untuk Analisis Data Tingkat Insidensi Malaria

II. MALARIA INCIDENCE RATE /***************************************************************** * Program: Malaria Incidence2.sas * Author: Etih Sudarnika * Purpose: Evaluate malaria incidence rates in an Olyset * studyfrom Bangka,Indonesia. Cases were detected from * logbooks of persons presenting with malaria at the * local health centers. There were 11 subdistrict * in the study, 6 intervention and 5 control areas. * Intervention areas encourage households to regenerate * olyset nets whereas control areas did not. * * Inputs: Excel datafile with 1 record per case. Variables of * interest: * PKMID:Health Center * Treatment: group 1=treatment 0=control * Months: month ill * sex_code: 0=Male 1=Female * CUF: 1=age <= 5 years 0= age >5 * * Excel worksheet with census data for the * subdistricts. * * * Created: Nov 18, 2009 * Revisions I: Nov 19, 2009 * Revision II: Jan 11, 2010 *****************************************************************/ * 1 2 3 4 5 6 7 ; *23456789012345678901234567890123456789012345678901234567890123456 7890123456; OPTIONS MACROGEN SYMBOLGEN NODATE; LIBNAME net "E:\NCSU\MONITORING\"; %LET net = E:\NCSU\MONITORING\; %MACRO getdata(dataset,sheet,name); PROC IMPORT DATAFILE = "&net.&dataset..xls" OUT = &name DBMS = EXCEL REPLACE; SHEET = "&sheet";

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GETNAMES=YES; RUN; PROC CONTENTS; RUN; %MEND getdata; %getdata(Incidence,ForSAS, cases); %getdata(Census data,Sheet1, census); PROC FORMAT; VALUE treat 1="treatment" 0="control" ; VALUE months 6="6/2007" 7="7/2007" 8="8/2007" 9="9/2007" 10="10/2007" 11="11/2007" 12="12/2007" 13="1/2008" 14="2/2008" 15="3/2008" 16="4/2008" 17="5/2008" 18="6/2008" 19="7/2008" ; VALUE pkm 1="Sungai Liat" 2="Sinar Baru" 3="Bakam" 4="Petaling" 5="Puding Besar" 6="Gunung Muda" 7="Pemali" 8="Belinyu" 9="Riau Silip" 10="Batu Rusa" 11="Kenanga" ; VALUE sex 0="Male" 1="Female" ; VALUE vector 1="Pv" 2="Pf" 3="mix" ; VALUE prev 1="Low" 2="Medium" 3="High" ; RUN;

113

DATA cases2; FORMAT month2 months. treatment treat. pkmid pkm. pkm $15. sex_code sex. plasmodium vector. prevalence prev.; SET cases; IF pkmid=1 THEN pkm="Sungai Liat"; IF pkmid=2 THEN pkm="Sinar Baru"; IF pkmid=3 THEN pkm="Bakam"; IF pkmid=4 THEN pkm="Petaling"; IF pkmid=5 THEN pkm="Puding Besar"; IF pkmid=6 THEN pkm="Gunung Muda"; IF pkmid=7 THEN pkm="Pemali"; IF pkmid=8 THEN pkm="Belinyu"; IF pkmid=9 THEN pkm="Riau Silip"; IF pkmid=10 THEN pkm="Batu Rusa"; IF pkmid=11 THEN pkm="Kenanga"; RUN; DATA census; FORMAT pkm $15.; SET census(RENAME=(F1=PKM CU5=Popkids)); RUN; PROC SORT DATA=cases2; BY PKM; RUN; PROC SORT DATA=census; BY PKM; RUN; DATA incidence; MERGE cases2 census; BY PKM; IF num=375 THEN sex_code=1; TotPopB=.; IF treatment=0 THEN TotpopB=15927; ELSE IF treatment=1 THEN TotPopB=14306; DROP num date test F5 F6 F7; RUN; DATA kids; SET incidence; IF CUF=0 THEN DELETE; Logpop=log(popkids); format month_code months.; RUN; PROC SORT DATA=kids; BY month_code; RUN; PROC MEANS DATA=kids NWAY NOPRINT n mean; CLASS pkmid month_code treatment prevalence; id popkids logpop; var age; OUTPUT OUT=count(drop=_type_ _freq_) n=n sum=total mean=average; RUN; PROC EXPORT DATA=count OUTFILE="E:\NCSU\MONITORING\count2" DBMS=EXCEL; RUN; %getdata(count3,COUNT, count2); Title "MALARIA INCIDENCE DATA";

114

PROC PRINT DATA=count2 (obs=20); RUN; Title "MALARIA INCIDENCE WITHOUT AGE VARIABLE"; PROC GENMOD DATA=count2; CLASS treatment(ref="1") Prevalence month_code; MODEL n=treatment prevalence month_code/dist=poisson link = log offset = logpop scale = pearson; RUN; Title "MALARIA INCIDENCE WITH AGE VARIABLE"; PROC GENMOD DATA=count2; CLASS treatment(ref="1") Prevalence month_code; MODEL n=treatment prevalence month_code average_age/dist=poisson link = log offset = logpop scale = pearson; RUN; %getdata(count3-SB,COUNT, countsb); Title "MALARIA INCIDENCE DATA EXLUDE SINAR BARU HEALTH CENTER"; PROC PRINT DATA=countsb (obs=20); RUN; Title "MALARIA INCIDENCE WITHOUT AGE VARIABLE (EXLUDE SINAR BARU HEALTH CENTER)"; PROC GENMOD DATA=countsb; CLASS treatment(ref="1") Prevalence month_code; MODEL n=treatment prevalence month_code/dist=poisson link = log offset = logpop scale = pearson; RUN; Title "MALARIA INCIDENCE WITH AGE VARIABLE (EXLUDE SINAR BARU HEALTH CENTER)"; PROC GENMOD DATA=countsb; CLASS treatment(ref="1") Prevalence month_code; MODEL n=treatment prevalence month_code average_age/dist=poisson link = log offset = logpop scale = pearson; RUN; Title "GEE MALARIA INCIDENCE WITHOUT AGE VARIABLE"; PROC GENMOD DATA=count2; CLASS treatment(ref="1") Prevalence month_code PKMID; MODEL n=treatment prevalence month_code/dist=poisson link = log offset = logpop scale = pearson; REPEATED SUBJECT=PKMID/TYPE=EXCH; RUN; Title "GEE MALARIA INCIDENCE WITH AGE VARIABLE"; PROC GENMOD DATA=count2; CLASS treatment(ref="1") Prevalence month_code PKMID; MODEL n=treatment prevalence month_code average_age/dist=poisson link = log offset = logpop scale = pearson;

115

REPEATED SUBJECT=PKMID/TYPE=EXCH; RUN; %getdata(count3-SB,COUNT, countsb); Title "GEE MALARIA INCIDENCE DATA EXLUDE SINAR BARU HEALTH CENTER"; PROC PRINT DATA=countsb (obs=20); RUN; Title "GEE MALARIA INCIDENCE WITHOUT AGE VARIABLE (EXLUDE SINAR BARU HEALTH CENTER)"; PROC GENMOD DATA=countsb; CLASS treatment(ref="1") Prevalence month_code PKMID; MODEL n=treatment prevalence month_code/dist=poisson link = log offset = logpop scale = pearson; REPEATED SUBJECT=PKMID/TYPE=EXCH; RUN; Title "GEE MALARIA INCIDENCE WITH AGE VARIABLE (EXLUDE SINAR BARU HEALTH CENTER)"; PROC GENMOD DATA=countsb; CLASS treatment(ref="1") Prevalence month_code PKMID; MODEL n=treatment prevalence month_code average_age/dist=poisson link = log offset = logpop scale = pearson; REPEATED SUBJECT=PKMID/TYPE=EXCH; RUN;

117

Lampiran 5 Program SAS untuk Analisis Data Kajian Kasus Kontrol Berpadanan

III. MATCHED CASE CONTROL STUDY /***************************************************************** ************** * Program: caco.sas * Author: Etih Sudarnika * * Inputs: Excel datafile * * * Created: Dec 1, 2009 * Revisions I Dec 8, 2009 * Revisions II Dec 9, 2009 * Revision III Dec 10, 2009 * Revision IV Dec 13, 2009 ****************************************************************** *************/ * 1 2 3 4 5 6 7 ; *23456789012345678901234567890123456789012345678901234567890123456 7890123456789; OPTIONS MACROGEN SYMBOLGEN NODATE; LIBNAME cone "E:\NCSU\CASE CONTROL\"; %LET cone = E:\NCSU\CASE CONTROL\; %MACRO getdata(dataset,sheet,name); PROC IMPORT DATAFILE = "&cone.&dataset..xls" OUT = &name DBMS = EXCEL REPLACE; SHEET = "&sheet"; GETNAMES=YES; RUN; PROC CONTENTS; RUN; %MEND getdata; %getdata(CACO,cases, cases); %getdata(CACO,control, control); PROC FORMAT; VALUE pkm 1="Sungai Liat" 2="Sinar Baru" 3="Bakam" 4="Petaling" 5="Puding Besar" 6="Gunung Muda" 7="Pemali" 8="Belinyu" 9="Riau Silip" 10="Batu Rusa" 11="Kenanga" ;

118

VALUE yes 1="yes" 0="no" ; VALUE case 1="cases" 0="control" ; VALUE net 1="1=Not use" 2="2=Not washed" 3="3=Not heated" 4="4=Some time heated" 5="5=Routine heated" ; VALUE netnew 0="otherwise" 1="Routine heated" ; VALUE netheat 1="1=otherwise" 2="2=heated" 3="3=Routine heated" ; VALUE heating 0="otherwise" 1="Heated & Routine heated" ; RUN; DATA cases1; SET cases; match= _n_ ; case=1; RUN; DATA control1; SET control; match = ceil(_n_/2); case=0; DATA main; SET cases1 control1; RUN; DATA main2; SET main; IF havenets=0 or usenetwhensleep=0 then net=1; ELSE IF usenetwhensleep=1 and netwashed=0 then net=2; ELSE IF usenetwhensleep=1 and netwashed=1 and heating=0 then net=3; ELSE IF usenetwhensleep=1 and netwashed=1 and heating=1 and routineheated=0 then net=4; ELSE IF usenetwhensleep=1 and netwashed=1 and heating=1 and routineheated=1 then net=5; DATA main3; SET main2; FORMAT usenetwhensleep yes. netwashed yes. routinewashed yes. heating yes. routineheated yes. PKMID pkm. IRS yes. coil yes. aerosol yes. electric yes. lotion yes. nothing yes. tinmining yes. ricefield yes. garden yes. pond yes. bush yes. cages yes. ventilationnet yes. case case. net net.;

119

RUN; TITLE "MATCHED CASE CONTROL DATA I (FIVE CATEGORIES)"; PROC PRINT DATA=main3 (OBS=10); RUN; PROC FREQ; TABLES match*case*havenets/CHISQ CMH; RUN; PROC LOGISTIC; MODEL case=havenets; strata match; RUN; PROC FREQ; TABLES match*case*usenetwhensleep/CHISQ CMH; RUN; PROC LOGISTIC; MODEL case=usenetwhensleep; strata match; RUN; PROC FREQ; TABLES match*case*netwashed/CHISQ CMH; RUN; PROC LOGISTIC; MODEL case=netwashed; strata match; RUN; PROC FREQ; TABLES match*case*routinewashed/CHISQ CMH; RUN; PROC LOGISTIC; MODEL case=routinewashed; strata match; RUN; PROC FREQ; TABLES match*case*heating/CHISQ CMH; RUN; PROC LOGISTIC; MODEL case=heating; strata match; RUN; PROC FREQ; TABLES match*case*routineheated/CHISQ CMH; RUN; PROC LOGISTIC; MODEL case=routineheated; strata match; RUN; PROC FREQ; TABLES match*case*net/CHISQ CMH; RUN; PROC LOGISTIC DATA=main3; CLASS net(ref='5=Routine heated'); strata match; MODEL case=net; CONTRAST '3 vs 4' net 0 0 1 -1/ESTIMATE=EXP; CONTRAST '3 vs 5' net 1 1 2 1/ESTIMATE=EXP; CONTRAST '3&4 vs 5' net 1 1 1.5 1.5/ESTIMATE=EXP; CONTRAST '1&2&3 vs 4' net 0.33 0.33 0.33 -1/ESTIMATE=EXP; CONTRAST '1&2&3 vs 5' net 1.33 1.33 1.33 1/ESTIMATE=EXP;

120

CONTRAST '1&2&3&4 vs 5' net 1.25 1.25 1.25 1.25/ESTIMATE=EXP; RUN; PROC LOGISTIC DATA=main3; CLASS net(ref='5=Routine heated') IRS coil aerosol electric tinmining ventilationnet housewall(ref='1'); strata match; MODEL case=net IRS coil aerosol electric tinmining ventilationnet housewall; RUN; DATA main4; SET main3; IF net=1 or net=2 or net=3 or net=4 then netnew=0; ELSE IF net=5 then netnew=1; FORMAT netnew netnew.; RUN; TITLE "MATCHED CASE CONTROL DATA II (1=ROUTINE HEATED, 0=OTHERWISE)"; PROC PRINT DATA=main4 (OBS=10); RUN; PROC LOGISTIC DATA=main4; CLASS netnew(ref='Routine heated'); strata match; MODEL case=netnew; RUN; PROC LOGISTIC DATA=main4; CLASS netnew(ref='Routine heated') IRS coil aerosol electric tinmining ventilationnet housewall(ref='1'); strata match; MODEL case=netnew IRS coil aerosol electric tinmining ventilationnet housewall; RUN; PROC LOGISTIC DATA=main4; CLASS netnew(ref='Routine heated') IRS coil electric housewall(ref='1'); strata match; MODEL case=netnew IRS coil electric housewall; RUN; PROC LOGISTIC DATA=main4; CLASS netnew(ref='Routine heated') IRS housewall(ref='1'); strata match; MODEL case=netnew IRS housewall; RUN; PROC LOGISTIC DATA=main4; CLASS netnew(ref='Routine heated') IRS; strata match; MODEL case=netnew IRS; RUN; PROC LOGISTIC DATA=main4; CLASS netnew(ref='Routine heated')housewall(ref='1'); strata match; MODEL case=netnew housewall; RUN; PROC LOGISTIC DATA=main4; CLASS netnew(ref='Routine heated')coil; strata match; MODEL case=netnew coil; RUN; PROC LOGISTIC DATA=main4;

121

CLASS netnew(ref='Routine heated')electric; strata match; MODEL case=netnew electric; RUN; DATA main5; SET main3; IF net=1 or net=2 or net=3 then netnew2=1; ELSE IF net=4 then netnew2=2; ELSE IF net=5 then netnew2=3; FORMAT netnew2 netheat.; RUN; TITLE "MATCHED CASE CONTROL DATA III (1=OTHERWISE, 2=HEATED, 3=ROUTINE HEATED)"; PROC PRINT DATA=main5 (OBS=10); RUN; PROC LOGISTIC DATA=main5; CLASS netnew2(ref='3=Routine heated'); strata match; MODEL case=netnew2; CONTRAST '1 vs 2' netnew2 1 -1/ESTIMATE=EXP; CONTRAST '1 vs 3' netnew2 2 1/ESTIMATE=EXP; CONTRAST '2 vs 3' netnew2 1 2/ESTIMATE=EXP; CONTRAST '1&2 vs 3' netnew2 3 3/ESTIMATE=EXP; CONTRAST '1 vs 2&3' netnew2 1.5 0/ESTIMATE=EXP; RUN; PROC LOGISTIC DATA=main5; CLASS netnew2(ref='3=Routine heated') IRS coil aerosol electric tinmining ventilationnet housewall(ref='1'); strata match; MODEL case=netnew2 IRS coil aerosol electric tinmining ventilationnet housewall; RUN; DATA main6; SET main3; IF net=1 or net=2 or net=3 then netnew3=0; ELSE IF net=4 or net=5 then netnew3=1; FORMAT netnew3 heating.; RUN; TITLE "MATCHED CASE CONTROL DATA IV (1=HEATED AND ROUTINE, 0=OTHERWISE)"; PROC PRINT DATA=main6 (OBS=10); RUN; PROC LOGISTIC DATA=main6; CLASS netnew3(ref='Heated & Routine heated'); strata match; MODEL case=netnew3; RUN; PROC LOGISTIC DATA=main6; CLASS netnew3(ref='Heated & Routine heated')IRS coil aerosol electric tinmining ventilationnet housewall(ref='1'); strata match; MODEL case=netnew3 IRS coil aerosol electric tinmining ventilationnet housewall; RUN;

122

123

Lampiran 6 Paper publikasi I ACCEPTABILITY AND UTILIZATION OF LONG LASTING INSECTICIDAL NETS TO PROTECT MALARIA IN BANGKA DISTRICT, INDONESIA Etih Sudarnika1, Mirnawati Sudarwanto1, Asep Saefuddin1, Umi Cahyaningsih1, Upik Kesumawati Hadi1, Rita Kusriastuti2, Jodi Vanden Eng3, Daowen Zhang4, William A. Hawley5 1 Faculty of Veterinary Medicine, Bogor Agricultural University, Bogor, Indonesia; 2Directorat of Zoonosis, General of Disease Control and Environment Health, Ministry of Health of Indonesia, Jakarta, Indonesia; 3 Centers for Disease Control and Prevention, Atlanta, Georgia; 4Departement of Statistics, North Carolina State University; 5United Nations Children’s Fund, Jakarta, Indonesia

Correspondence mail to: [email protected], [email protected]. ph./fax.:+62-251-8628811 ABSTRACT This research was done to determine the utilization, washing and heat assisted regeneration treatment of long lasting insecticidal nets (LLINs) in Bangka District – Indonesia. Research was conducted in one year period from September 2007 to August 2008. Socialization and education of importance of LLINs utilization was maintained during the research period. LLINs utilization was periodically surveyed every 3 months. The result showed that amount of LLINs owned by people during the research period was increase, as well as the utilization, washing and heat assisted regeneration treatment. However the utilization rate in vulnerable group were still low. In general, utilization rate for children under five years old was ranging from 63.1% to 75.8%; for pregnant women were ranging from 36.0% to 53.6%. This research was part of supporting data for the main research entitled the Protective Efficacy of Olyset Nets in Bangka District. This research divided study area into two areas, namely treatment area (where the heat assisted regeneration on LLINs after washing was applied) and control area (where the heat assisted regeneration on LLINs after washing was not applied). General Estimating Equations (GEE) for binomial distribution showed no difference in utilization and washing rate for LLINs between treatment and control area. Keywords: generalized estimating equations, heat assisted regeneration, Olyset, permethrin treated LLINs. INTRODUCTION Malaria is one of the health diseases problems in Indonesia in order to decrease the case retaliate to the international commitment in Millennium Development Goals (Hunt 2007). As one of the ratification country, Indonesia is doing work which already agreed in the commitment, including decreasing the malaria case rate (Stalker 2007). Presumably about 45% of Indonesia people are living in malaria risk contagious area. Annual Malaria Incidence (AMI) in Indonesia in 2007 is 19.67% per 1000 people with Case Fatality Rate (CFR) of 0.57%. Bangka Belitung Province is one of the malaria endemic areas in Indonesia, which have AMI of 29.3 per 1000 people (MoH RI 2008). Some efforts have been done in avoiding malaria transmission. One way is minimizing the contact between human and mosquitoes as the malaria vector, with utilization of bed nets. Long Lasting Insecticidal Nets (LLINs) is an

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effective way to avoid malaria since it act as a physical barrier to mosquitoes, the insecticide has toxic effects on mosquitoes and many insecticides such as permethrin have exito-repellent properties that affect the behavior of mosquitoes by reducing the rate of entry into houses and increasing the rate of early exit from houses (Mathenge et al. 2001). LLINs is bed nets contains insecticide either incorporated into or coated around fibres which resists multiple washes (al least 20) and whose biological activity for personal protection and/or vector control lasts as long as the life of the net itself (e.g. around 3 years for polyester nets, 5 years for polyethylene). There are two types of approved bed nets by WHO, namely Olyset® (made from polyethylene with permethrin incorporated) and PermaNet (made from polyester, surface treatet with deltamethrin insectide) (Guillet et al. 2001, Kulkarni 2006, Shaw 2006, Coticelli 2007). The consistency utilization of LLINs can reduce malaria transmission to 90% (Gimnig et al. 2003; ter Kuile 2003). By 2006, UNICEF is cooperating with Department of Health Republic of Indonesia is introducing LLINs in Indonesia. In Bangka district about 60,000 LLINs already distributed to the people. Type of LLINs distributed is made from polyethylene with permethrin incorporated. Priority is given to pregnant women and children under five years old, except for area with high malaria endemicity, which all people are receiving. First stage of distribution is along with measles mass vaccination program, next stage is when the pregnant women or children under five years old check up in local health center, auxiliary health center or village delivery post. LLINs made from polyethylene and permethrin insecticide incorporated is new technology in Indonesia, therefore the acceptance rate is unknown. This research is done to determine the utilization rate of LLINs in Bangka district people, especially in pregnant women and children under five years old. MATERIALS AND METHODS This research is part of supporting data of main research titling “The Protective Efficacy of Olyset® Nets in Bangka District” durating from September 2007 to August 2008. Research is done with cooperation from Faculty of Veterinary Medicine, Bogor Agricultural University Indonesia, UNICEF, CDC Atlanta, and Bangka District Health Service. The main research is conducted to determine effect of heat assisted regeneration of Olyset® bed nets efficacy used in Bangka District. For this the research area is divided into two areas: first is treatment area, doing heat assisted regeneration to LLINs bed nets after washing; second is control area, not doing the heat assisted regeneration to LLINs after washing. Bangka District has 11 local health center work areas. Each treatment group and control group is divided according to local health center work areas, with each local health center is classified into 3 strata based on initial research data malaria prevalence in each area. Classification is conducted so that malaria prevalence is the same for treatment area and control area. The three strata are: 1) Low: local health center of Petaling and Batu Rusa; 2) Medium: local health center of Pemali, Bakam, Puding Besar and Riau Silip; 3) High: local health center of Belinyu, Gunung Muda, Sungai Liat, Sinar Baru and Kenanga. Then

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selected randomly of health center at each strata for inclusion in the treatment or control areas. Treatment area consists of of local health center of Sungai Liat, Sinar Baru, Bakam, Petaling, Puding Besar and Gunung Muda. Control area consists of of local health center of Pemali, Belinyu, Riau Silip, Batu Rusa and Kenanga. This paper study is to determine acceptability and utilization of bed nets to protect malaria transmission in Bangka District. Study Area Bangka District is located in Bangka Island, Indonesia with acreage of 295,068 Hectares, population of 237,053, population density is 80 people/km2. Education rate is: finishing Elementary School 36%, not finishing Elementary School 27%, finishing Junior High School 18%, finishing Senior High School 14%, finishing University 1.5% and the rest is not attending school (3.5%). A large portion of population working as farmer, fishermen, tin mine workers and traders. Bangka district climate is tropic with annual rainfall by 2007 is 18.5 to 394.7 mm, lowest rainfall is in August. Temperature is between 26.2°C to 28.3°C. While humidity is varied between 71% to 88%; sunlight intensity is 18.0 to 66.1%; atmospheric pressure is 1009.1 to 1011.1 mb. Geographical condition of the island is mostly lowlands; 25% are swamp areas and 4% is hilly. Study Design Survey is done in initial period of research, then every three months held until one year, therefore a total of four surveys is conducted. Sampling technique in survey is done with multistage sampling. In each Local health center is chosen 3-4 village with probability proportional to size method if the work area in that local health center is more than 3 villages, but conducted surveys in all villages if there are less than or equal to 3 villages. Then for each village is selected 3 hamlets randomly if it having more than 3 hamlets, but conducted survey in all hamlets if there are less than or equal to 3 hamlets. So for each local health center is having 50 respondents and targeted all of 550 respondents from all local health center for surveying. Total respondent for each survey is listed in Table 1. An interview is held for each respondent with a questionnaire. Unit sample draw for baseline survey is house with LLINs, while on next survey is house having pregnant woman or children five years olds. Interview is done with questionnaire sheet in baseline survey and Personal Digital Assistant (PDA) on the next three surveys. Tabel 1 Total respondent for each survey Survey

Sampling Unit

Tools

#HH

# people # net # PW # CUF

I

HH having LLINs

Paper

530

2401

708

28

524

II

HH having PW or CUF

PDA

565

2322

660

50

551

III

HH having PW or CUF

PDA

549

2221

652

30

517

IV

HH having PW or CUF

PDA

559

2343

605

41

580

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Legend: HH = Households PW = Pregnant Women CUF = Children Under Five years old Public Awareness and Extension During the research period, socializations and extentions was also held for the people so that the community will be familiar with proper utilization of LLIN , realize the benefit, and utilization priority for children and pregnant woman. For people in treatment area, an additional information is given regarding to its application and function of heat assisted regeneration on LLINs after washing. Other information given are malaria transmission, signs of malaria and how to avoid it. Education activity at first stage is done via trainings to volunteers of health posts. Then the volunteers are asked to forward the trainings information during monthly activity and community meetings. The next socialization activity is held each month by the health district officers, staff of local health centers, and midwife to the head of dusun, volunteers and the habitans. Socialization was continuously carried out during the period of study. Statistical Analysis To compare the utilization rate of LLINs in treatment area and control area then the data were analyzed using Generalized Estimating Equations (GEE) (Hardin et al. 2003) adjusting for prevalence level and survey period. Statistical analyses were performed using SAS version 9.2 (SAS Institute, Cary, NC,USA).

RESULTS LLINs Ownership and Utilization LLINs were distribute to households which have children under five years old or pregnant woman, except the location which had high rate of malaria endemicity which all households will received LLINs (which varies in amount, related to the households members). LLINs ownership in Bangka District is shown in Table 2. Tabel 2 Distribution amount of LLINs in households ownership Amount of LLINs

Amount

%

Amount

%

Amount

%

Amount

%

0

0

0.0

65

11.5

40

7.3

61

10.9

1

388

73.2

356

63.0

379

69.0

400

71.6

2

114

21.5

130

23.0

118

21.5

92

16.5

3

23

4.3

12

2.1

11

2.0

3

0.5

4

3

0.6

2

0.4

1

0.2

3

0.5

Survey I

Survey II

Survey III

Survey IV

127

5

1

0.2

6

1

0.2

530

100

Total

565

100

549

100

559

100

Unit sample for baseline survey is household which have LLINs, while in next three survey is household which owned children under five years old or pregnant woman. Because of this difference in unit sample, in the Survey 1 in showing all households is having LLINs which actually it doesn’t. When Survey 1 is neglected, in Table 2 is showing 90% of households having children under five years old or pregnant women is having at least 1 LLINs and majority is having only 1 LLIN. Maximum LLINs owned is 6. LLINs utilization Despite having several LLINs, not every household is using LLINs or all of its LLINs. Table 3 shows utilization rate of LLINs by respondent in Bangka District.

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Tabel 3 Utilization rate of LLINs in households Amount of LLINs used 0 1 2 3 4 Total

Survey I

Survey II

Survey III

Survey IV

Amount

%

Amount

%

Amount

%

Amount

%

24 412 83 11 0 530

4.5 77.7 15.7 2.1 0 100

99 341 55 5 0 500

19.8 68.2 11.0 1.0 0 100

52 383 71 3 0 509

10.2 75.2 13.9 0.6 0 100

70 370 52 4 2 498

14.1 74.3 10.4 0.8 0.4 100

Table 3 shows that generally there are more than 10% of households not using their LLINs. About 75% using only one LLINs and about 15% using more than one LLINs. Many reason were told by respondents regarding not using LLINs. Majority are worried about the insecticide contained in LLINs. Others are felt uncomfortable and hot, difficult to hang it and as a reserve for households having more than 1 LLINs. Other than knowing the LLINs utilization rate, it is also important to know distribution trend of number households members using LLINs, this is to see how much LLINs is used as a protection device against mosquitoes. Table 4 is showing number of household member using LLIN. Tabel 4 Number of household member using LLINs Amount

Survey I Count

Survey II %

Count

Survey III

%

Count

Survey IV

%

Count

57

10.8

185

32.7

104

18.9

137

24.5

1

30

5.7

16

2.8

21

3.8

14

2.5

2

124

23.4

82

14.5

116

21.1

92

16.5

3

206

38.9

187

33.1

189

34.4

198

35.4

4

83

15.7

71

12.6

91

16.6

87

15.6

5

24

4.5

18

3.2

23

4.2

22

3.9

6

5

0.9

5

0.9

5

0.9

5

0.9

7

1

0.2

1

0.2

3

0.5

1

0.2

559

100.0

8 Total

%

0

530

100.0

565

100.0

549

100.0

From table 4, it can be seen that generally in each survey, the largest percentage (about 33.1% - 38.9%) is 3 households members were using LLINs. One interesting fact is percentage of households not using LLINs is quite high, about 10.8% - 32.7%.

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Percent of Vulnerable Groups Sleeping Under Nets Children under five years old and pregnant women is vulnerable groups to malaria. Malarian in pregnant women can causes anemia, low birth weight, prematurity, maternal mortality, stillbirth and neonatal mortality (Brabin 1983; Luxemburger et al. 2001; Guyatt et al. 2004; Wort et al. 2006; Gamble et al. 2009). When it came to children, the effects are anemia, cerebral malaria and cause of death (Newton 1996; Lines 1997; Fischer 2002). Therefore it is main priority to avoiding malaria on pregnant women and children under five years old. Tabel 5 Distribution of children under five years old and pregnant women using LLINs Survey

Amount of children

Amount of children using LLINs

I II III IV

524 551 517 580

397 348 388 405

Percentage of children using LLINs

Amount of pregnant women

75.8% 63.1% 75.1% 69.8%

28 50 30 41

Amount of pregnant women using LLINs 15 18 15 21

Percentage of pregnant women using LLINs 53.6% 36.0% 50.0% 51.0%

Table 5 is showing distribution of children under five years old and pregnant women using LLINs in Bangka District. From table 5 appear that not all children under five years old and pregnant women sleeping under LLINs. Percentage of infants using LLINs is around 63.1% to 75.8%, meanwhile for pregnant women the percentage is much lower, numbering 36.0% to 53.6%. Level of Application in Treatment Area and Control Area Distribution of households members, children under five years old and pregnant women using LLINs in treatment and control area can be seen in Table 6. Tabel 6 Distribution of households members in using LLINs in treatment and control area Treatment Area

Control Area

Survey

Amount of households members

Amount of households members LLINs

Percentage of members using LLINs

Amount of households members

Amount of households members LLINs

Percentage of members using LLINs

I II III IV

1302 1336 1271 1275

792 617 710 685

60.8 46.2 55.9 53.7

1099 986 950 1068

593 535 619 624

54.0 54.3 65.1 58.4

From Table 6 shows that distribution of households members using LLINs is almost the same, both in treatment area and in control area. It also shows that less than 70% of households members is using LLINs in Bangka District. While percentage of children under five years old and pregnant women in using LLINs in treatment and control area is showed in Table 7. From Table showed that percentage of children under five years old using LLINs is almost

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equal both in treatment and control area. However for pregnant woman percentage in treatment area looks maller compare to control area. Tabel 7 Percentage of children under five years old and pregnant women in using LLINs in treatment and control area Treatment Area

Survey

I II III IV

Amount of Infant

Amount of Infant using LLINs

270

205

304

Control Area

Treatment Area Amount of Amount Pregnant of Woman Pregnant using Woman LLINs

Control Area Amount of Pregnant Woman

Amount of Pregnant Woman using LLINs

Amount of Infant

Amount of Infant using LLINs

75.9

254

192

75.6

14

6

42.9

14

8

57.1

187

61.5

247

161

65.2

36

15

41.7

14

3

21.4

285

203

71.2

232

185

79.7

15

5

33.3

15

10

66.7

324

226

69.8

255

179

70.2

27

12

44.4

14

9

64.3

%

%

%

Statistical examination used for comparing utilization rate of LLINs in treatment area and control area is generalized estimating equations (GEE) for binomial distribution. Factors that also considered in modeling other than heating treatment is prevalence of malaria in Local health center which divided into 3 categories: low, medium and high. This prevalence factor is considered as stratification factor in choosing treatment area and control area. Other factor is survey period, consist of 4 periods. Statistical examination is shown in Table 8. Tabel 8 GEE Analysis to evaluate utilization rate difference of LLINs in treatment and control area Variable

Regression Coefficient -0.0726 1.5247 1.1567

Treatment vs Control Low Prevalence vs High Medium Prevalence vs High Survey I vs IV 0.6212 Survey II vs IV -0.4302 Survey III vs IV 0.1758 * significant at α=0.05

Confidence Interval 95% Lower limit Upper limit 0.1043 0.1318 0.1770 1.8717 0.1241 1.3999

0.4863 <0.0001* <0.0001*

0.1581 0.1338 0.1405

<0.0001* 0.0013* 0.2108

0.9311 -0.1680 0.4511

P Value

From Table 8, it appears that no difference in utilization rate LLINs between treatment and control area. Interesting point gained from analysis is area with low prevalence and medium prevalence are having higher utilization rate compared to high prevalence. Area with low prevalence is have utilization rate LLINs e1,5247 or 4.59 times higher with confidence interval of 95% (1.19 – 6.50) compared to area with high prevalence in malaria. As for area with medium malaria prevalence is having utilization rate LLINs of 3.18 (CI 95%; 1.13-4.05) times higher than area with high malaria prevalence. Also with survey period, shows increment in community awareness in using LLINs in line with survey period. From Table 8 shown that regression coefficient in Survey II compared to Survey IV is valued negative which mean that utilization rate of LLINs in Survey II is smaller than that of Survey IV.

%

131

DISCUSSION AND CONCLUSION From result of survey conducted 4 times in 1 year research period showed that possession coverage of LLINs in Bangka District is good, which is reaching >85% at the end of research (Table 1). But is also need to pay attention is amount of LLINs distribution per households. Table 3 is shown that in general people only using 1 bed net per household, and other bed nets is reserved. In turn this will inhibit next LLINs ownership, that is for newly pregnant after bed nets distribution period also newly born babies or new citizen from outside of Bangka District. They are the priority group in using LLINs, on the other hand there are numbers of unused LLINs. This is a challenge to Local health center staff to retain the unused LLINs and redistributed it to those who in need it. As for the ownership is good enough, on the contrary the utilization rate is not satisfying. This is come from survey result, which showed that percentage of households using minimum 1 of several LLINs possessed is ranging 67.3% 81.1% (Table 4, in neglection of Survey I). From that percentage, not all households members sleep using LLINs. From Table 6 it is shown that in general utilization rate is still low which ranging from 46.2% to 65.1%. Low percentage of mass utilization of LLINs can reduce the protection level of LLINs to malaria (Maxwell et al. 2002; Hawley et al. 2003a; Tekhleimanot et al. 2007). LLINs have a important function other than as a protection against an individual, that is the protection of the community. The community protections are: 1) reducing mosquito population in community; 2) shortening mosquito lifespan; 3) mass coverage might divert mosquitoes from human to animal biting, thereby reducing human to human transmission. LLINs is one effective and efficient way of preventing malaria. Particularly on vulnerable groups, namely pregnant women and children. Many studies have shown that the use of LLIN can reduce the prevalence of malaria and parasitemia in children (Holtz et al. 2002; Koram et al. 2003; Sharma et al. 2009), prevent the transmission of malaria, delayed the median time-to-first parasitemia, reducing anemia suffer due to malaria, and reducing infant mortality (Fegan et al. 2007; Eisele et al. 2005; Phillips-Howard et al. 2003a; Phillips-Howard et al. 2003b; ter Kuile et. al. 2003a; ter Kuile et. al . 2003b). As well as in pregnant women, many studies have shown that its use in pregnant women may increase the average increased mean birth weight, reduced low birth weight, reduced miscarriages/ stillbirths, reduced placental parasitaemia, and reduced severe malarial anemia during pregnancy, (Hawley et al. 2003b ; ter Kuile et al. 2003b; Gamble et al. 2007). From this study it appears that the utilization of LLINs to pregnant women and children under five years old is still low. Utilization in children under five years old ranged from 63.1% - 75.8%, and in pregnant women ranged from 36.0% - 53.6%. Most of the reasons not to use LLINs during sleep in children under five years old is that parents are concerned about the content of insecticide in LLINs can poison children. Another reason is they have to use mosquito coil or other mosquito protection tool. The common reasons in pregnant women is they feel hot when sleeping under LLINs. Some other little say because they already use mosquito coil or other mosquito protection tool. This is a challenge for governments and health workers to improve public education about the

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importance of malaria prevention and the use of LLINs, especially for vulnerable groups, namely pregnant women and children under five years old. This research is supporting research for the primary research that aims to determine the influence of heat-assisted regeneration of protective efficacy of LLINs. The results of this study showed that both the treatment and control areas have the same levels of LLINs utilization (Table 8). This is a good information for the main study, because level of utilization of LLINs is not a factor affecting the outcome of research. The interesting thing about the analysis results of Generalized Estimating Equations (GEE) in Table 8 is that there are differences in LLINs utilization levels in the area with different prevalence rates. This is the important information for the government and health workers in Bangka to improve and prioritize education in areas with high and medium malaria prevalence rates. Education provided by health workers and government showed encouraging results. This can be seen on the results of GEE analysis in Table 8 which shows that the level of LLINs utilization increase with survey period. ACKNOWLEDGEMENT Appreciation is forwarded to Department of Health, Republic of Indonesia which has been fully supporting this research, also to UNICEF which fully funded this research. Also appreciation to CDC Atlanta for its support form initial research design, conduction to data analysis. Other appreciation is also to Bangka District Health Division Board, Bangka Belitung Provincial Health Division Board, staffs of Local health center, volunteer and head of hamlet in Bangka District. Lastly, a word of thanks to all the team members.

REFERENCES [BPS Kabupaten Bangka] Badan Pusat Statistik Kabupaten Bangka. 2007. Bangka Dalam Angka 2006. Bangka: BPS dan BAPEDA Kab. Bangka. Brabin BJ. 1983. An analysis of malaria in pregnancy in Africa. Bulletin ofthe World Health Organization, 61(6): 1005-1016. Coticelli P. 2007. WHOPES and Its Impact on Long-lasting Insecticidal Net availability. Africa Fighting Malaria Occasional Paper. April 23, 2007. [DEPKES RI] Departemen Kesehatan Republik Indonesia. 2008. Profil Kesehatan Indonesia 2007. Jakarta: DEPKES RI. Eisele TP, Macintyre K, Yukich J, Ghebremeskel T. 2006. Interpreting household survey data intended to measure insecticide-treated bednet coverage: results from two surveys in Eritrea. Malaria J 2006, 5(36): 1 – 8.

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Fegan GW, Noor AM, Akhwale EW, Cousens S, Snow RW. 2007. Eff ect of expanded insecticide-treated bednet coverage on child survival in rural Kenya: a longitudinal study. The Lancet 370: 1035–1039. Fischer PR Bialek R. 2002. Prevention of Malaria in Children. TRAVEL MEDICINE 34: 493-498. Gamble C., Ekwaru PJ, Garner P, ter Kuile FO. 2007. Insecticide-Treated Nets for the Prevention of Malaria in Pregnancy: A Systematic Review of Randomised Controlled Trials. PLoS Medicine 4(3): 506-515. Gamble CL, Ekwaru JP, ter Kuile FO. 2009. Insecticide-Treated Nets for Preventing Malaria in Pregnancy (Review). Liverpool: JohnWiley & Sons, Ltd. Gimnig JE, Vulule JM, Lo TQ, Kamau L, Kolczak MS, Phillips-Howard PA, Mathenge EM, ter Kuile FO, Nahlen BL, Hightower AW, Hawley WA, 2003. Impact of permethrin-treated bed nets on entomologic indices in an area of intense year round malaria transmission. Am J Trop Med Hyg 68 (Suppl 4):16–22. Guillet P. 2004. Overview of LLIN technologies. Meeting on development, production and distribution of Long Lasting Insecticidal Nets (LLINs). Johannesburg, South Africa 23-24 September 2004. Guyatt HL and Snow RW. 2004. Impact of Malaria during Pregnancy on Low Birth Weight in Sub-Saharan Africa. Clin. Microbiol. Rev. 17: 760–769.

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Hawley WA, Phillips-Howard PA, ter Kuile FO, Terlouw DJ, Vulule JM, Ombok M, Nahlen BL, Gimnig JE, Kariuki SK, Kolczak MS, Hightower AW, 2003a. Community-wide effects of permethrin-treated bed nets on child mortality and malaria morbidity in Western Kenya . Am J Trop Med Hyg 68 (Suppl 4): 121–127. Hawley WA, ter Kuile FO, Steketee RS, Nahlen BL, Terlouw DJ, Gimnig JE, Shi YP, Vulule JM , Alaii JA, Hightower AW, Kolczak MS, Kariuki SK, Phillips-Howard PA. 2003b. Implications of the Western Kenya permethrintreated bed net study for policy, program implementation, and future research. Am J Trop Med Hyg 68 (Suppl 4): 168–173. Hardin JW, Hilbe JM. 2003. Generalized Estimating Equations. Chapman & Washington DC: Hall/CRC. Holtz TH, Marum LH, Mkandala C, Chizani N, Roberts JM, Macheso A, Parise ME, Kachur SP. 2002. Insecticide-treated bednet use, anaemia, and malaria parasitaemia in Blantyre District, Malawi. Trop Med Int Health 7(3): 220 – 230. Hunt P. 2007. Poverty, Malaria and the right to health Exploring the connections. UN CHRONICLE 4: 81 – 85. Koram KA, Owusu-Agyei S, Fryauff DJ, Anto F, Atuguba F, Hodgson A, Hoffman SL, Nkrumah FK. 2003. Seasonal profiles of malaria infection, anaemia, and bednet use among age groups and communities in northern Ghana. Trop Med Int Health 8(9): 793–802. Kulkarni M. 2006. Update on Long Lasting Insecticidal Nets (LLINs). Malaria Matters 15:1-2. Lines Jo. 1997. Severe malaria in children and transmission intensity. The Lancet 350: 813. Luxemburger C, McGready R, Kham A, Morison L, Cho T, Chongsuphajaisiddhi T, White NJ, Nosten F. 2001. Effects of malaria during pregnancy on infant mortality in an area of low malaria transmission. Am J Epidemiol 154(5): 459–465. Mathenge EM, Gimnig JE, Kolczak M, Ombok M, Irungu LW, Hawley WA. 2001. Effect of permethrin-impregnated nets on exiting behavior, blood feeding success, and time of feeding of malaria mosquitoes (Diptera: Culicidae) in Western Kenya. J Me. Entomol 38(4): 531-536. Maxwell CA, Msuya E, Sudi M, Njunwa KJ, Carneiro IA, Curtis CF. 2002. Effect of community-wide use of insecticide-treated nets for 3–4 years on malarial morbidity in Tanzania. Trop Med Int Health 7(12): 1003 – 1008. [MoH RI] Ministry of Health of Republik Indonesia. 2008. Indonesian Health Profile 2007. Jakarta: MOH RI. Newton CRJC. Cerebral malaria in children. 1996. J Child Neurol 11:257 Phillips-Howard PA, Nahlen BL, Alaii JA, ter Kuile FO, Gimnig JE, Terlouw DJ, Kachur SP, Hightower AW, Lal AA, Schoute E. Oloo A, Hawley WA. 2003a. The Efficacy of permethrin-treated bed nets on child mortality and

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morbidity in Western Kenya I. Development of infrastructure and description of study site. Am J Trop Med Hyg 68 (Suppl 4): 3 - 9. Phillips-Howard PA, Nahlen BL, Kolczak MS, Hightower AW, ter Kuile FO, Alaii JA, Gimnig JE, Arudo J, Vulule JM, Odhacha A, Kachur SP, Schoute E, Rosen DH, Sexton JD, Oloo AJ, Hawley WA, 2003b. Efficacy of permethrin-treated bed nets in the prevention of mortality in young children in an area of high perennial malaria transmission in western Kenya. Am J Trop Med Hyg 68 (Suppl 4): 23–29. Sharma SK, Tyagi PK, Upadhyay AK, Haque MA, Mohanty SS, Raghavendra K, Dash AP. 2009. Efficacy of permethrin treated long-lasting insecticidal nets on malaria transmission and observations on the perceived side effects, collateral benefits and human safety in a hyperendemic tribal area of Orissa, India. Acta Tropica 112: 181–187. Shaw WD. Long-Lasting Insecticide Treated Nets: A Success In Technology Transfer. Malaria Matters 2006:15:3-4. Stalker P. 2007. Let Speak Out for MDGs: Achieving the Millennium Development Goals in Indonesia. Jakarta: BAPPENAS and UNDP. Teklehaimanot A., Sachs JD, Curtis C. 2007. Malaria control needs mass distribution of insecticidal bednets. The Lancet 369: 2143-2146. ter Kuile FO, Terlouw DJ, Kariuki SK, Phillips-Howard PA, Mirel LB, Hawley WA, Friedman JF, Shi YP, Kolczak MS, Lal AA, Vulule JM, Nahlen BL, 2003a. Impact of permethrin-treated bed nets on malaria, anemia, and growth in infants in an area of intense perennial malaria transmission in Western Kenya. Am J Trop Med Hyg 68 (Suppl 4): 68–77. ter Kuile FO, Terlouw DJ, Phillips-Howard PA, Hawley WA, Friedman JF, Kolczak MS, Kariuki SK, Shi YP, Kwena AM, Vulule JM, Nahlen BL, 2003b. Impact of permethrin-treated bed nets on malaria and all cause morbidity in young children in an area of intense perennial malaria transmission in Western Kenya: cross-sectional survey. Am J Trop Med Hyg 68 (Suppl 4): 100–107. Wort UU, Hastings I, Mutabingwa TK, Brabin BJ. 2006. The impact of endemic and epidemic malaria on the risk of stillbirth in two areas of Tanzania with different malaria transmission Patterns. Malaria Journal 5(89): 1 – 10.

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Lampiran 7 Paper Publikasi II

Malaria Incidence Rate of Children Under five Years Old in Intervention Area of Heat Assisted Regeneration for Permethrin Treated Long Lasting Insecticidal Nets and Control Area in Bangka District Etih Sudarnika1, Mirnawati Sudarwanto1, Asep Saefuddin1, Umi Cahyaningsih1, Upik Kesumawati Hadi1, Rita Kusriastuti2, Jodi Vanden Eng3, Daowen Zhang4, William A. Hawley5 1

Faculty of Veterinary Medicine, Bogor Agricultural University, Bogor, Indonesia; 2Directorat of Zoonosis, General of Disease Control and Environment Health, Ministry of Health of Indonesia, Jakarta, Indonesia; 3 Centers for Disease Control and Prevention, Atlanta, Georgia; 4Departement of Statistics, North Carolina State University; 5United Nations Children’s Fund, Jakarta, Indonesia

Correspondence mail to: [email protected], [email protected]. ph./fax.:+62-251-8628811

ABSTRACT Long lasting insecticidal nets (LLINs) is one effective way to prevent malaria for children under five years old. Permethrin treated LLINs is one type of LLINs which is recommended by WHO. Several studies have shown that these types of LLINs requiring heat assisted regeneration after washing to enhance the biological activity of insecticide that contained in the LLINs fibers. This study aimed to compare the incidence rates of malaria in children under five years old who live in the intervention area (where the heat assisted regeneration on LLINs after washing was applied) and control area (where the heat assisted regeneration on LLINs after washing was not applied). Data of malaria cases was collected from laboratory log book at all health centers in Bangka District, in the period of June June 2007 until July 2008. Data were analyzed with generalized estimating equations for Poisson distribution. The results showed that the annual parasite incidence in children under five years old in Bangka District was 1.62%, namely 1.84% in treatment areas and 1.42% in control areas. There was not significantly different between the treatment and control areas. Keywords: generalized estimating equations, heat assisted regeneration, incidence rate, Olyset, permethrin treated LLINs

INTRODUCTION Utilizing LLINs is one of the effective ways to prevent malaria in infants. Several research had shown that the utilization of LLINs as a malaria protection devices in infants in malaria endemic area can reduce malaria prevalence and parasitemia in infants (Holtz et al. 2002; Koram et al. 2003; Sharma et al. 2009), prevent malria contagion, delayed the median time-to-first parasitemia, reduce anemia case caused by malaria and decrease infants death caused by malaria. (Fegan et al. 2007; Eisele et al. 2005; Phillips-Howard et al. 2003a; PhillipsHoward et al. 2003b; ter Kuile et. al. 2003a; ter Kuile et. al. 2003b).

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Indonesia is one of the malaria endemic countries, located in tropical region with high annual rainfall, swamp topography and community lives close to environment is causing the life cycle of mosquito as the malaria vector is running smoothly. According to Malaria Endemicity Map on 2007, estimated that 45% of Indonesia peole is living in risk area of malaria contagious location. One of the malaria endemic area in Indonesia is Bangka District, located in Bangka Belitung Province. This malaria endemic area category is classificated as medium endemic indicated by AMI rate of 29.3 per 1000 people on 2007. (MoH RI 2008) In 2006, UNICEF cooperating with Ministry of Health Republic of Indonesia is introducing LLINs. In Bangka District alone is recorded about 60,000 LLINs had been distributed. The distributed LLINs is Olyset brand, made form polyethylene, produced by Sumitomo Chemical Company of Japan. The manufacturers of Olyset, formerly recommended that nets be regenerated after washing by placing the nets in bags in the sun. However, it has been reported that these nets will regenerate spontaneously within 15 days under tropical conditions (WHOPES 2001). Several researches had shown that Olyset was still maintain high biological activity after several washing cycles with no heat assisted regeneration (Vythilingam et al. 1996; Tami et al. 2004; Jeyalakshmi et al. 2006; Sharma et. al. 2009b). However other studies showed that Olyset net is not able to regenerate spontaneously to increase the biological activity under the room temperature (the temperature below 60 oC) (N’Guessan et al. 2001; Gimnig et al. 2005; Lindblade et al. 2005). There is not much information available regarding heat regeneration effect on Permethrin treated LLINs application. Faculty of Veterinary Medicine – Bogor Agricultural University was cooperating with UNICEF, CDC Atlanta and Bangka District Health Service conducted the study titled The Protective Efficacy of Olyset Nets in Bangka District which intended to recognize impact of heat assisted regeneration to Olyset bed nets efficacy. The research is conducted from September 2007 to August 2008. This paper study is act as a supporting research from the previous mentioned research and designed to recognize difference of malaria incidence rate between intervention area (which doing heat assisted regeneration ) and control area.

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RESEARCH METHODS Study Area Bangka District is located in island of Bangka-Indonesia with acreage of 295,068 Hectares, population of 237,053, population density is 80 people/km2 Bangka district climate is tropic with annual rainfall by 2007 is 18.5 to 394.7 mm, lowest rainfall is in August. Temperature is between 26.2°C to 28.3°C. While humidity is varied between 71% to 88%; sunlight intensity is 18.0 to 66.1%; atmospheric pressure is 1009.1 to 1011.1 mb. Mining industry is one of prime sector for this district, due to mineral resources in relatively large reserves were found all over the island. There are many illegal minners in Bangka, which were pit digging in mining area, and left a large number of deserted large sized pit everywhere. This condition in turn is a potential breeding place for mosquitoes. Geographical condition of the island is mostly lowlands; 25% are swamp areas and 4% is hilly (Statistical Center Bangka District 2007). Determination of Treatment and Control Areas Bangka District has 11 local health center work areas. Each treatment group and control group is divided according to local health center work areas, with each local health center is classified into 3 strata based on initial research data malaria prevalence in each area. Classification is conducted so that malaria prevalence is the same for treatment area and control area. The three strata are: 1) Low: local health center of Petaling and Batu Rusa; 2) Medium: local health center of Pemali, Bakam, Puding Besar and Riau Silip; 3) High: local health center of Belinyu, Gunung Muda, Sungai Liat, Sinar Baru and Kenanga. Then selected randomly of health center at each strata for inclusion in the treatment or control areas. Treatment area consists of of local health center of Sungai Liat, Sinar Baru, Bakam, Petaling, Puding Besar and Gunung Muda. Control area consists of of local health center of Pemali, Belinyu, Riau Silip, Batu Rusa and Kenanga. Intervention applied in this research is heat regeneration of permethrin treated LLINs after washing, that is wrapping the washed bed nets with black plastic bag, then sun drying it for 4 – 6 hours, and then install it back. Control is by conventional method, that is washing thepPermethrin treated LLINs then drying it up in the air (shade place) and then install it back. Bed nets washing is scheduled every three months. During the research period, socializations and extentions was also held for the people so that the community will be familiar with proper utilization of LLIN , realize the benefit, and utilization priority for children and pregnant woman. Socialization is conducted by District Health Service staffs, Health Center, Auxiliary Health Center, Village Delivery Post, volunteer and head of hamlets. For community in intervention area, additional information is given regarding heat assisted regeneration so that could be understand on application and effect of heat assisted regeneration treatment on LLINs after washing. This socialization is conducted continuously during the the period of study. Net use surveys were

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conducted research.

every 3 month to evaluate community participation level in this

Data Collection Data collection of malaria case is performed periodically every month by copying the data form laboratory log book in every health centers in Bangka District. Definition of malaria cases are children under five years old is stated who tested positive by examination of Plasmodium parasites in the laboratory. Clinical examination and dignontic rapid test are not recorded as a case. If in one community health center work area is found a case of malaria which originated from other community health center work area, then the case is put in the list of patient domicile address. Data taken is covering: 1) Demography data (age, gender and address) and 2) diagnostic result data and type of Plasmodium. Data gathered is malaria case period of June 2007 to July 2008. Population data of children under five years old were taken from Bangka District Health Service. Data Analysis To compare the malaria incidence chindren under five years old intervention area and control area then the data were analyzed using Poisson regression model (McCullagh et al. 1989) adjusting for malaria prevalence level and months of monitoring). Statistical analyses were performed using SAS version 9.2 (SAS Institute, Cary, NC, USA). Mapping is done using ArcGIS version 9.3.1 (ESRI, Redlands, CA, USA). RESULTS AND DISCUSSION Incident Rate at All Work Areas of Community Health Center Bangka District with its ecological condition as an island which surrounded by sea, swamp area, plenty palm oil and an abundant of abandoned wild tin mining pit is providing a potential breeding place for malaria mosquitoes. Malaria incidence rate on children under five years old is varied refer to health center work area and surveillance time. Malaria incidence rate during monitoring period from June 2007 to July 2008 in 11 work areas of health center is provided at Figure 1. Darker color gradation is showing increment in malaria incident value. During the research in Bangka District, malaria incidence in infants was 1.62%, with incident details in intervention area and control area were 1.84% and 1.42% respectively. Highest incident rate was in Health Center of Sinar Baru. As for other health center, both for the intervention area and control area is almost the same that is 0.46% - 3.72% in intervention area and 0.38% - 3.51% in control area.

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Belinyu 3.51

Gunung Muda 3.72 Riau Silip 0.38 Sinar Baru 9.52Sungailiat Pemali 0.83

0.65 Kenanga 0.58

Bakam 1.34 Puding Besar 2.15

Legend Batu Rusa 1.27

0.38 0.39 - 0.46 0.47 - 0.58 0.59 - 0.65

Petaling 0.46

0.66 - 0.83 0.84 - 1.27 1.28 - 1.34 1.35 - 2.15 2.16 - 3.72 3.73 - 9.52

Figure 1 Malaria incidence rate in health center in Bangka District period of June 2007-July 2008. Fluctuations of malaria incidence rate on children under five years old in each health center for one year period can be seen in Figure 2 and 3. Malaria incidence rate in children under five years old in Sinar Baru Health Center is the highest compared to other health center. The fluctuations are clearly seen in Figure 2 and dark color is always appeared in Figure 3. Before November 2007 there is no electricity line to the Sinar Baru Health Center, which in turn has no power to operate the microscope in laboratory and blood slide examination cannot be done for malaria suspected people, that caused case was appearing low.

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Figure 2 Malaria incident rate on children under five years old in each community health center.

Figure 3 Malaria incident rate in children under five years old per month in each health center.

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Work area of Sinar Baru Health Center is just one village, which also had the smallest area compared to others which had working area in sub-district size (Figure 1 and 3). Large parts of the area consist of beach, swamp and plenty of active tin mines and abandoned tin mines. Climate condition, topography and environment is very supportive for malaria mosquitoes. But the question mark goes to why malaria incidence rate for infants is very extreme compared to other areas which had similar geographical features such as Kenanga Health Center. Few factors considered to causing the high rate on Malaria incidence in Sinar Baru are: small work area coverage, which relatively had a homogenous condition, compared to others work area. In Sinar baru Health Center, almost all area is malaria hotspot. On other wide area, hotspot only found in several places which, will become relatively lower incident rate. Small area coverage also means better accessibility to health center. This condition is causing almost all malaria case in infants are recorded in health center logbook. In every work area the facility also complement with the auxiliary health centers. Malaria examination procedure in Bangka District is require all suspected patient to be taken its blood sample and the slide is taken to the health center and having a laboratory examination. But due to distance from auxiliary health centers to health center, in several areas the procedure did not run well, so not all the malaria patient were logged especially in the vast work areas. Small area coverage also facilitate good education activity, in return community awareness also high when they are feeling ill they will go to health center. Other important factor is microscopist skill in detecting Plasmodium. Even in initial research intensive training had been given, but regular coaching and refreshing training are also needed to increase their capability. Periodical cross check is also important to recognize microscopist errors in performing examination. Incident Rate in Intervention Area and Control Area High incidence rate in Sinar Baru will affect overall incidence rate in intervention area. This affect can be seen in Figure 4 which shows incident rate fluctuation in intervention area and control area. Figure 4 shows that malaria incidence rate in children under five years old in intervention area and control area is almost the same if Sinar Baru data was neglected.

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Figure 4 Malaria incidence rate in children under five years old in intervention area and control area. The result from Poisson regression model to see difference of malaria incidence rate in children under five years old in intervention area and control area is shown in Table 1. In Poisson regression model, also included is covariate prevalence rate and surveillance month, because those covariate is also affecting malaria incidence rate. From analysis, it was showed that malaria incidence rate in children under five years old is not significantly different between intervention area and control area. Tabel 1 Poisson regression model to determine difference in malaria incidence rate in intervention area and control area Variable

Regression Coefficient

Treatment vs control Prevalence low vs High Prevalence medium vs high Jun'07 vs Jul'08 Jul'07 vs Jul'08 Aug'07 vs Jul'08 Sep'07 vs Jul'08 Oct'07 vs Jul'08 Nov'07 vs Jul'08 Dec'07 vs Jul'08 Jan'08 vs Jul'08 Feb'08 vs Jul'08 Mar'08 vs Jul'08 Apr'08 vs Jul'08 May'08 vs Jul'08 Jun'08 vs Jul'08 * significant at α=0.05

0.04 -0.87 -0.52 2.04 1.97 1.55 1.72 1.05 1.77 1.00 1.31 1.19 0.54 1.46 0.89 0.36

Confidence Interval 95%

P Value

Lower limit Upper limit -0.33 -1.41 -0.95 0.61 0.53 0.07 0.26 -0.51 0.31 -0.58 -0.20 -0.35 -1.16 -0.04 -0.71 -1.40

0.42 0.34 0.09 3.47 3.40 3.03 3.18 2.61 3.22 2.57 2.83 2.73 2.23 2.95 2.49 2.11

0.818 0.001* 0.018* 0.005* 0.007* 0.040* 0.021* 0.189 0.017* 0.214 0.090 0.130 0.533 0.057 0.277 0.691

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Malaria incidence rate in children under five years old in heat regeneration intervention area of LLINs and control area is not significantly different. Some research had shown that Olyset is still maintaining its biological activity after several washing cycles without heat regeneration (Vythilingam et al. 1996; Tami et al. 2004; Jeyalakshmi et al. 2006; Sharma et. al. 2009). On the other research, resulting that in room temperature (temperature below 60 oC) cannot spontaneously regenerate which can re-increase activity of biological insecticide contents (N’Guessan et al. 2001; Gimnig et al. 2005; Lindblade et al. 2005). Case control study conducted in Bangka District also showed that a regular heat assisted regeneration to LLINs was giving a better protection from malaria for children under five years old (OR=1.97; CI 95%:1.13-3.45) compared to not regularly doing heat regeneration (Sudarnika 2010, Dissertation – Bogor Agricultural University, unpublished). Several factors were considered have influencing outcome of this research. First factor is not all LLINs owners in intervention area were doing heat regeneration. From the three months periodic surveys shows that until the last survey (9 months after intervention), rate of peoples who owned LLINs and did the heat regeneration was 75.2% and only 59.4% which did the heat regeneration routinely after washing. In the second survey (6 months after intervention) only 55% which do the heat regeneration after washing, and only 36.9% who do heat regeneration routinely (Sudarnika 2010, Dissertation – Bogor Agricultural University, unpublished). Other factors is utilization rate of LLINs in children under five years old which relatively low both in intervention area and control area, ranging from 63.1% 75.8% (Sudarnika 2010, Dissertation – Bogor Agricultural University, unpublished). The low rate of LLINs utilization coverage is causes low impact of LLINs to malaria incidence rate. Tekhlemainot et al. 2007 stated that LLINs have a important function other than as a protection against an individual, that is the protection of the community. The community protections are: 1) reducing mosquito population in community; 2) shortening mosquito lifespan; 3) mass coverage might divert mosquitoes from human to animal biting, thereby reducing human to human transmission. Many research had been done and showed that a high rate on utilization coverage was important to maximizing the effect for community health. Binka et al. showed that mortality rates of children living in control compounds increased with increasing distance from the nearest ITN compound (Binka et al. 1998). Gimnig et al. have shown that mosquito abundance was reduced in compounds lacking ITNs but located close to compounds with ITNs (Gimnig et. Al. 2003). Hawley et al. also showed that people who didn’t use ITNs (insecticide-permethrin-treated bed nets) that lived in 300 meter away form people who use ITNs with high rate of utilization is receiving protection as much those who were living in with ITNs (Hawley et al. 2003). Other research in coastal Kenya also showed that rates of severe clinical malaria were lower in children living in houses lacking ITNs but living in villages where most families had nets (Howard et al. 2000). Maxwell et al. 2003 is founding that highly significant reductions in malarial morbidity for children aged 6 months to 2 years are living in area utilizing bed nets with high rate of ITNs coverage, even several

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people doesn’t use the ITNs or ITNs have torn nets. This caused by the combination of of the mass effect of the village’s nets on the vector populations and the personal protection to the individual children Several other information is needed to support the result from this research, as skill level of microscopist in detecting Plasmodium, accessibility rate for people to reach health center both in intervention area and control area and bioassay laboratory testing to LLINs. It needs a longer period of time in order to recognize effects of long time intervention. CONCLUSION Malaria Incident Rate in heat regeneration intervention area of LLINs and control area was not significantly different. Some other information such as microscopist skill level in detecting Plasmodium, health centers accessibility rate for surrounding community in intervention area and control area, bioassay laboratory testing to LLINs were needed to support the result of this research. ACKNOWLEDGEMENT Appreciation is forwarded to Community Health Center laboratory staff in Bangka District , Department of Health, Republic of Indonesia which has been fully supporting this research, also to UNICEF which fully funded this research. Also appreciation to CDC Atlanta for its support form initial research design, conduction to data analysis. Other appreciation is also to Bangka District Health Division Board, Bangka Belitung Provincial Health Division Board, staffs of Local Health Center, volunteer and head of dusun in Bangka District. Least but not last is for all researcher involved in this research. REFERENCES Binka FN, Indome F, Smith T, 1998. Impact of spatial distribution of permethrinimpregnated bed nets on child mortality in rural northern Ghana. Am J Trop Med Hyg 59: 80–85. Eisele TP, Macintyre K, Yukich J, Ghebremeskel T. 2006. Interpreting household survei data intended to measure insecticide-treated bednet coverage: results from two surveis in Eritrea. Malaria Journal 5(36): 1 – 8. Fegan GW, Noor AM, Akhwale EW, Cousens S, Snow RW. 2007. Eff ect of expanded insecticide-treated bednet coverage on child survival in rural Kenya: a longitudinal study. The Lancet 370: 1035–1039. Gimnig JE, Kolczak MS, Hightower AW, Vulule JM, Schoute E, Kamau L, Phillips-Howard PA, ter Kuile FO, Nahlen BL, Hawley WA. 2003. Effect of permethrin-treated bed nets on the spatial distribution of malaria vectors in western Kenya. Am J Trop Med Hyg 68 (Suppl 4): 115–120.

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Gimnig JE, Lindblade KA, Mount DL, Atieli FK, Crawford S, Wolkon A, Hawley WA. Dotson EM. 2005. Laboratory Wash Resistance of Long-lasting Insecticidal Nets. Trop Med Int Health: 10 (10):1022–1029. Hawley WA, Phillips-Howard PA, ter Kuile FO, Terlouw DJ, Vulule JM, Ombok M, Nahlen BL, Gimnig JE, Kariuki SK, Kolczak MS, Hightower AW, 2003. Community-wide effects of permethrin-treated bed nets on child mortality and malaria morbidity in Western Kenya . Am J Trop Med Hyg 68 (Suppl 4): 121–127. Holtz TH, Marum LH, Mkandala C, Chizani N, Roberts JM, Macheso A, Parise ME, Kachur SP. 2002. Insecticide-treated bednet use, anaemia, and malaria parasitaemia in Blantyre District, Malawi. Trop Med Int Health 7(3): 220 – 230. Howard SC, Omumbo J, Nevill C, Some ES, Donnelly CA, Snow RW, 2000. Evidence for a mass community effect of insecticide-treated bednets on the incidence of malaria on the Kenyan coast. Trans R Soc Trop Med Hyg 94: 357–360. Jeyalakshmi T, Shanmugasundaram R, Murthy B. 2006. Comparative efficacy and Persistency of Permethrin in Olyset® Net and Conventionally Treated Net Againts Aedes Aegypti and Anopheles Stephensi. J Amer Mosquito Control Assoc 22(1):107-110. Koram KA, Owusu-Agyei S, Fryauff DJ, Anto F, Atuguba F, Hodgson A, Hoffman SL, Nkrumah FK. 2003. Seasonal profiles of malaria infection, anaemia, and bednet use among age groups and communities in northern Ghana. Trop Med Int Health 8(9): 793–802. Lindblade KA, Dotson EM, Hawley WA. Bayoh N, Williamson J, Mount D, Olang G, Vulule J, Slutsker L, Gimnig J. 2005. Evaluation of long-lasting Insecticide-treated bed nets after 2 years of household use. Trop Med Int Health 10 (11): 1141–1150. Maxwell CA, Msuya E, Sudi M, Njunwa KJ, Carneiro IA, Curtis CF. 2002. Effect of community-wide use of insecticide-treated nets for 3–4 years on malarial morbidity in Tanzania. Trop Med Int Health 7(12): 1003 – 1008. [MoH RI] Ministry of Health of Republik Indonesia. 2008. Indonesian Health Profile 2007. Jakarta: MOH RI.

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McCullagh P and Nelder JA. 1989. Generalized Linear Models 2nd ed. London: Chapman and Hall. N’Guessan R, Darriet F, Doannio JM, Chandre F & Carnevale P. 2001. Olyset Net efficacy against pyrethroid-resistant Anopheles gambiae and Culex quinquefasciatus after 3 years’ field use in Coˆ te d’Ivoire. Med Vet Entomol 15, 97–104. Phillips-Howard PA, Nahlen BL, Alaii JA, ter Kuile FO, Gimnig JE, Terlouw DJ, Kachur SP, Hightower AW, Lal AA, Schoute E. Oloo A, Hawley WA. 2003a. The Efficacy of permethrin-treated bed nets on child mortality and morbidity in Western Kenya I. Development of infrastructure and description of study site. Am J Trop Med Hyg 68 (Suppl 4): 3 - 9. Phillips-Howard PA, Nahlen BL, Kolczak MS, Hightower AW, ter Kuile FO, Alaii JA, Gimnig JE, Arudo J, Vulule JM, Odhacha A, Kachur SP, Schoute E, Rosen DH, Sexton JD, Oloo AJ, Hawley WA, 2003b. Efficacy of permethrin-treated bed nets in the prevention of mortality in young children in an area of high perennial malaria transmission in western Kenya. Am J Trop Med Hyg 68 (Suppl 4): 23–29. Sharma SK, Tyagi PK, Upadhyay AK, Haque MA, Mohanty SS, Raghavendra K, Dash AP. 2009a. Efficacy of permethrin treated long-lasting insecticidal nets on malaria transmission and observations on the perceived side effects, collateral benefits and human safety in a hyperendemic tribal area of Orissa, India. Acta Tropica 112: 181–187. Sharma SK, Upadhyay AK, Haque MA, Tyagi PK, Mohanty SS, Raghavendra K, Dash AP. 2009b. Field Evaluation of Olyset Nets: A Long-Lasting Insecticidal Net Against Malaria Vectors Anopheles culicifacies and Anopheles fluviatilis in a Hyperendemic Tribal Area of Orissa, India. J Med Entomol 46(2): 342-350. Tami A, Mubyazi G, Talbert A, Mshinda H, Duchon S, Lengeler C. 2004. Evaluation of OlysetTM insecticide-treated nets distributed seven years previously in Tanzania. Malaria Journal 3(19):1-9. Vythilingam I, Pascua BP, Mahadevan S. 1996. Assessment of A New Type of Permethrin Impregnated Mosquito Net. Journal of Bioscience 7(1):63-70. Teklehaimanot A., Sachs JD, Curtis C. 2007. Malaria control needs mass distribution of insecticidal bednets. The Lancet 369: 2143-2146. ter Kuile FO, Terlouw DJ, Kariuki SK, Phillips-Howard PA, Mirel LB, Hawley WA, Friedman JF, Shi YP, Kolczak MS, Lal AA, Vulule JM, Nahlen BL, 2003a. Impact of permethrin-treated bed nets on malaria, anemia, and growth in infants in an area of intense perennial malaria transmission in Western Kenya. Am J Trop Med Hyg 68 (Suppl 4): 68–77.

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ter Kuile FO, Terlouw DJ, Phillips-Howard PA, Hawley WA, Friedman JF, Kolczak MS, Kariuki SK, Shi YP, Kwena AM, Vulule JM, Nahlen BL, 2003b. Impact of permethrin-treated bed nets on malaria and all cause morbidity in young children in an area of intense perennial malaria transmission in Western Kenya: cross-sectional survei. Am J Trop Med Hyg 68 (Suppl 4): 100–107. [WHOPES] World Health Organization Pesticides Evaluation Scheme. 2001. Review of Olyset Net and Bifenthrin 10% WP. Report of the 5th WHOPES Working Group Meeting. WHO/CDS/WHOPES/2001.4. http://whqlibdoc.who.int/hq/2001/WHO_CDS_WHOPES_2001.4.pdf.

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Lampiran 8 Paper publikasi III

Effect of Heat Assisted Regeneration on Permethrin Treated Long Lasting Insecticidal Nets to Risk of Malaria in Children Under Five Years Old in Bangka District: A Case Control Study Etih Sudarnika1, Mirnawati Sudarwanto1, Asep Saefuddin1, Umi Cahyaningsih1, Upik Kesumawati Hadi1, Rita Kusriastuti2, Jodi Vanden Eng3, Daowen Zhang4, William A. Hawley5 1 Faculty of Veterinary Medicine, Bogor Agricultural University, Bogor, Indonesia; 2Directorat of Zoonosis, General of Disease Control and Environment Health, Ministry of Health of Indonesia, Jakarta, Indonesia; 3 Centers for Disease Control and Prevention, Atlanta, Georgia; 4Departement of Statistics, North Carolina State University; 5United Nations Children’s Fund, Jakarta, Indonesia

Correspondence mail to: [email protected], [email protected]. ph./fax.:+62-251-8628811 ABSTRACT Permethrin treated long-lasting insecticide treated nets (LLINs) are one of LLINs approved by the WHO Pesticide Evaluation Scheme for the prevention of malaria and other vector-borne diseases. However several investigations showed that most permethrin in the LLIN remained within the net fibers where it was unavailable to contact and kill mosquitoes without heat-assisted regeneration as originally recommended by the manufacturer. The objective of this study was to determine the association between heat assisted regeneration treatment in permethrin treated LLIN and malaria risk for children under five years old in the field condition. The research was carried out for one year, since September 2007 to August 2008, in Bangka District, Bangka Belitung Province. This research was conducted using matched case control study 1:2. Sample size was 138 cases and 276 controls. Association between risk factors and malaria cases was analyzed using conditional logistic regression model continued by contrast examination between risk factors. Results showed that odds for malaria in group which were not used, not washed, not heated, and not routinely heated the LLIN was two time higher (OR=1.97; CI 95%:1.13-3.45) compared with group which routinely heated their LLIN. Covariate which was associated with risk of malaria in children under five years old was the wall material. Concrete was better than woodboard with OR=1.77 (CI 95%; 1.02 – 3.08). Keywords: conditional logistic regression, heat assisted regeneration, matched case control study, Olyset, permethrin treated LLIN. INTRODUCTION Malaria was one of the public health problems in Indonesia, which still in high priority list due to relatively high on mortality rate especially in children under five years old and pregnant women. Referring to Malaria Endemicity Map, in 2007 there are estimated around 45% people or almost half of Indonesian population, live in high risk to malaria contagious location. Annual Malaria Incidence (AMI) in Indonesia in 2007 is 19.67 in 1000 people with Case Fatality Rate (CFR) are 0.57%. Bangka Belitung

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Province is one of the malaria endemic areas. AMI in 2007 is pointing in 29.3 in 1000 people.1 Infants were fragile group to malaria diseases, in which will have much fatal effect, compare to adults. More than 1-3 million children in the world died caused by malaria every year. Malaria effect to older children is close to that adults have, but for children under five years old were much fatal. Children under five that have had malaria could suffer anemia which, in time delayed its psychomotor development and growing process. Infants also more fragile to cerebral malaria and causes death.2,3,4 One way is minimizing the contact between human and mosquitoes as the malaria vector, with utilization of bed nets. Long Lasting Insecticidal Nets (LLINs) is an effective way in prevention malaria since it act as a physical barrier to mosquitoes, the insecticide has toxic effects on mosquitoes and many insecticides such as permethrin have exito-repellent properties that affect the behavior of mosquitoes by reducing the rate of entry into houses and increasing the rate of early exit from houses5. LLINs is bed nets contains insecticide either incorporated into or coated around fibres which resists to multiple washes (al least 20) and whose biological activity for personal protection and/or vector control lasts as long as the life of the net itself (e.g. around 3 years for polyester nets, 5 years for polyethylene). There are two types of approved bed nets by WHO, namely Olyset® (made from polyethylene with permethrin incorporated) and PermaNet (made from polyester, surface treatet with deltamethrin insectide)6,7,8,9. Olyset® already distributed in Indonesia by Ministry of Health of Indonesia and UNICEF since September 2006. Researches have been made to evaluate insecticidal bednets application, which in general stated the Permethrin treated LLINs are effective enough in order to prevent malaria compared to conventional bednets 10,11,12,13,14,15,16,17,18. On the other hand, several research is showing that Permethrin treated LLINs which recommended by WHO is decreasing its biological activity after 3 washing cycles 19,20 . The manufacturers of Permethrin treated LLINs were used in Bangka, formerly recommended that nets be regenerated after washing by placing the nets in bags in the sun. However, it has been reported that these nets will regenerate spontaneously within 15 days under tropical conditions (300C and 80% relative humidity) 21. Gimnig et al. had conducted laboratory test and concluded that Permethrin treated LLINs could be increasing its biological activity after heat regeneration at 600C temperature in 4 hour duration, and its biological activity remain low if heat regeneration was in 300C and 350C. This research showing that spontaneously regeneration cannot be done at room temperature even at tropical area. After 20 washing cycles, Permethrin treated LLINs still contain >50% of its initial insecticide concentration 19. Not much information on heat assisted regeneration of Permethrin treated LLINs on field condition. Based on this situation, a case control study is needed to determine the association between heats assisted regeneration treatment in Permethrin treated LLINs and malaria risk for children under five years old in Bangka District.

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RESEARCH METHODS This research is a part of supporting study to longitudinal study about The Protective Efficacy of Olyset Nets in Bangka District. Research conduction on cooperation between Faculty of Veterinary Medicine - Bogor Agricultural University, UNICEF, CDC Atlanta and Health Division Bangka District. Area of research is divided into two parts according to work area of Community Health Center, namely intervention area which doing the heat assisted regeneration on LLINs after washing and control area which not doing heat assisted regeneration on LLINs after washing. During the research period, socializations and extentions was also held for the people so that the community will be familiar with proper utilization of LLIN , realize the benefit, and utilization priority for children and pregnant woman. Socialization is conducted by District Health Service staffs, Health Center, Auxiliary Health Center, Village Delivery Post, volunteer and head of hamlets. For community in intervention area, additional information is given regarding heat assisted regeneration so that could be understand on application and effect of heat assisted regeneration treatment on LLINs after washing. This socialization is conducted continuously during the the period of study. Net use surveys were conducted every 3 month to evaluate community participation level in this research. Case control study is done in intervention area (which doing the heat assisted regeneration) that is health center working area of Sungai Liat, Sinar Baru, Petaling, Puding Besar and Gunung Muda. Study area Bangka District is located in island of Bangka-Indonesia with acreage of 295,068 Hectares, population of 237.053, population density is 80 people/km2 Bangka district climate is tropic with annual rainfall by 2007 is 18.5 to 394.7 mm, lowest rainfall is in August. Temperature is between 26.2°C to 28.3°C. While humidity is varied between 71% to 88%; sunlight intensity is 18.0 to 66.1%; atmospheric pressure is 1009.1 to 1011.1 mb. Mining industry is one of prime sector for this district, due to mineral resources in relatively large reserves were found all over the island. There are many illegal minners in Bangka, which were pit digging in mining area, and left a large number of deserted large sized pit everywhere. This condition in turn is a potential breeding place for mosquitoes. Geographical condition of the island is mostly lowlands; 25% are swamp areas and 4% is hilly 22.

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Study design Research design is based on nested matched case control study is a retrospective study in current longitudinal study23. The study duration is 12 months from September 2007 to September 2008, located in Bangka District, Bangka Belitung Province. Matching is done to control confounding factors, in this case is living area and ages. Case is children under five years old which have malaria during the longitudinal study. Cases confirmed by laboratory examination, while the information about the cases was taken from laboratory log book in Health Center and Hospital. Control is children under five years old not having malaria during longitudinal study. Each case is matched with 2 controls (1:2). Controls are children under five years old who lives in same Health Center working area and nearly similar age of those in case. Sample values studied are 138 cases and 276 controls. Risk factors data are using, washing and heating of Permethrin treated LLINs. Heat assisted regeneration treatment is to put washed bed nets into a black plastic bag, then have it sun dried for 4-6 hours. Covariates data are sex, indoor residual spraying (IRS), presence of local tin mines near house, wall types, presence of ventilation nets, and utilization of mosquito prevention devices beside LLINs. For respondent cases were also asked about Plasmodium types data. Utilization behavior on LLINs with permethrin insecticide in this case control study is using hierarchical questions as in Figure 1 below. Have bed nets?

If Yes

Utilize bed nets?

If Yes

Wash bed nets?

If Yes

Routinely wash?

Heating bed nets?

If Yes

Figure 1 Hierarchical structured questions on bed nets utilization questionnaires. Statistical Analysis Data was analyzed using conditional logistic regression models continued by contrast examination between risk factors24. Processing data is using SAS (Statistical Analysis Software v9.2, SAS Institute, Inc., Cary, NC, USA). Hypothetic for each risk factor were defined in tree diagram in Figure 2 below.

Heating routinely?

155

reason

reason

reason

No

No

No

No H0: OR=1 H1: OR≠1

Yes

Yes Have bed nets?

reason

Have bed nets?

Heating bed nets?

Wash bed nets?

H0: OR=1 H1: OR≠1 Yes Heating routinely?

No H0: OR=1 H1: OR≠1

Yes

H0: OR=1 H1: OR≠1

H0: OR=1 H1: OR≠1

Yes

Wash routinely?

Figure 2 Tree diagram questionnaire and hypothetical flow. RESULT Respondent Distribution Distribution of utilization, washing and regenerating of Permethrin treated LLINs in cases respondent group and controls shown in Table 1. Table 1 Utilization, washing and heating of permethrin treated LLINs Variables

Cases (n=138)

Controls (n=276)

n

%

n

%

Yes

108

78.26%

223

80.80%

No

30

21.74%

53

19.20%

Yes

70

64.81%

160

71.75%

No

38

35.19%

63

28.25%

Yes

56

80.00%

131

81.88%

No

14

20.00%

29

18.13%

Yes

36

64.29%

82

62.60%

No

20

35.71%

49

37.40%

Yes

34

60.71%

95

72.52%

No

22

39.29%

36

27.48%

Yes

23

67.65%

77

81.05%

No

11

32.35%

18

18.95%

Have Permethrin treated LLINs

Utilizing Permethrin treated LLINs while sleeping

Washing Permethrin treated LLINs

Washing Permethrin treated LLINs regularly

Heating Permethrin treated LLINs after washing

Heating Permethrin treated LLINs regularly

Table 1 shows that percentage value of respondent having, utilizing and washing Permethrin treated LLINs bednets are almost the same for cases group and controls group. Difference in heating bednets variable are shows that controls group has a higher percentage than cases group.

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Information on sex type, house and environment, utilization on mosquito protection device other than bed nets on Case and Control respondent are shown in Table 2. Table 2 Information on house, environment, mosquito protection device on respondent Covariate Sex type Female Male Public Health Center Area Sungai Liat Sinar Baru Bakam Petaling Puding Besar Gunung Muda IRS Yes No Utilization of coils Yes No Utilization of aerosol Yes No Utilization of electric Yes No Presence of tin mines / ex-mines Yes No Presence of ventilation nets Yes No Wall material Concrete Wood board Others

Cases (n=138) n %

Controls (n=276) n %

69 69

50.0 50.0

128 147

46.5 53.5

44 45 9 13 7 20

31.9 32.6 6.5 9.4 5.1 14.5

88 90 18 26 13 41

63.8 65.2 13.0 18.8 9.4 29.7

13 125

9.4 90.6

38 238

13.8 86.2

85 53

61.6 38.4

183 92

66.5 33.5

16 122

11.6 88.4

27 248

9.8 90.2

16 122

11.6 88.4

45 230

16.4 83.6

22 116

15.9 84.1

43 229

15.8 84.2

35 103

25.4 74.6

78 196

28.5 71.5

89 41 7

65.0 29.9 5.1

207 58 8

75.8 21.2 2.9

In Table 2 shown that for variance utilization of coils, utilization of aerosol, utilization of electric, presence of tin mines around the house and presence of house ventilation nets were having almost equal distribution percentage for case group and control group. From given data shows that mostly respondent utilizing coils were not having any tin mines / ex-mines in their surrounding and house ventilations were not using nets.

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Differences is present in IRS intervention, that is on control group respondent houses were applying IRS in the last one-year were higher compared to case group. Also for the wall material, that is percentage of houses using concrete wall were higher on control group compared to case group. Table 3, shows that Plasmodium which infected children under five years old. From table, describing that most of patients were infected by Plasmodium vivax. Tabel 3 Plasmodium Types Plasmodium Types Plasmodium vivax Plasmodium falciparum Mix Total

Amount

Percentage

103

74.6%

35

24.4%

0

0%

138

100%

Venn diagram defines frequency of respondent that utilize, wash and heating permethrin treated LLINs on Case and Control group on Figure 2, whilst analysis result using conditional logistic regression models were in Table 4 and Table 5.

(a) (b) Legend: A = Not having / Not using, B = Not washing, C, D, E, F = Washing, D = Washing regularly, E = Not regularly heating, F = Regularly heating Figure 3 Venn diagram on frequency of permethrin treated LLINs utilizing behavior of respondents; (a) case group (b) control group In Venn diagram in Figure 3 is showing respondent percentage that heating permethrin treated LLINs are 34/56 (61%) in case group and 95/131 (73%) in control group. While respondent that regularly heating permethrin treated LLINs is 23/56 (41%) in case group and 77/131 (59%) in control group.

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Tabel 4 Odds ratio value in utilizing, washing and heating permethrin treated LLINs

Models

Confidence Interval 95%

Odds Ratio

P-value

Lower Limit Upper Limit Not heating vs occasional heating

0.98

0.37

2.62

0.9673

Not heating vs routine heating

2.11

1.02

4.34

0.0438

Not heating & occasional heating vs routine heating

2.13

1.09

4.16

0.027

Not utilizing & not washing & not heating vs occasional heating

0.89

0.38

2.06

0.7849

Not utilizing & not washing & not heating vs routine heating

1.91

1.10

3.33

0.0218

Not utilizing & not washing & not heating & occasional heating vs routine heating

1.97

1.13

3.45

0.0173

In Table 4, showed that influencing factor which lead to reduce of malaria case on infants is by routinely heating permethrin treated LLINs (P < 0.05). Routine heating means always heating permethrin treated LLINs after washing. Odds households ratio value which not using, not washing, not heating and heating permethrin treated LLINs not routinely is 1.97 (CI 95%; 1.13 – 3.45) compared to routine heating the permethrin treated LLINs. This is meaning that odds of malaria in family not using, not washing, not heating and heating permethrin treated LLINs is twice of that compared to routine heating permethrin treated LLINs. Tabel 5 Odds ratio value in covariate factors Model

Odds Ratio

Confidence Interval 95% P-value Lower Limit Upper Limit

IRS not applied vs IRS applied

2.27

0.99

5.20

0.0517

coil not applied vs coil applied

1.36

0.83

2.21

0.2197

aerosol not applied vs aerosol applied

0.80

0.39

1.63

0.5352

electric not applied vs electric applied

1.58

0.81

3.07

0.1816

No tin mining near the house vs tin mining near the house

0.97

0.50

1.87

0.9174

Ventilation net not available vs ventilation net available

1.01

0.57

1.81

0.9664

Housewall: Wood vs concrete

1.77

1.02

3.08

0.0438

Housewall: others vs concrete

1.87

0.65

5.43

0.2492

In Table 5 showed that house wall is an important factor to preventing malaria. Concrete wall could protect almost twice compare to wooden wall, this can be seen from odds ratio valued 1.77 (CI 95%; 1.02 – 3.08).

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DISCUSSION AND CONCLUSION Permethrin treated LLINs made of polyethylene material and contains permethrin as insecticide. Insecticide is blended in polyethylene fibers during manufactured. Permethrin is filled inside fibers, then it diffuses to fibres surface therefore insecticide concentration is always maintained at surface. Wahing LLINs is important issue in LLINs maintenance, since dust and dirt collected by bed nets would obstruct biological activity of instecticide content on fibres surface. Research of Permethrin treated LLINs used for three years in Côte d’Ivoire showed that very dirty used Olyset® net have a lower biological activity compared to slightly dirty used Olyset® net 10. Nevertheless washing and sun drying will reduce or even rub out insecticide concantration in fibres surface, in sequent will reduce biological activity of LLINs. Result from N’Guessan et al. research is obtained that washed used Olyset net is having lower biological activity compared to slightly dirty used Olyset® net 10. The same result also given by evaluation research after two years of utilization, Lindblade et al. 2005 gain result that Olyset® will quickly lose its biological activity even insecticide concentration in net fibre is still high 20. This fact is shows that washing is not causing in decrement of insecticide concentration, the real problem is in insecticide bio-availability on the fiber surface. The manufacturers of Permethrin treated LLINs were used in Bangka, formerly recommended that nets be regenerated after washing by placing the nets in bags in the sun. However, it has been reported that these nets will regenerate spontaneously within 15 days under tropical conditions 21. Gimnig et al. 2005 studied the efficacy of LLINs after repeated washing under laboratory conditions and comparing six type of LLIN, including Olyset. Result showed that Olyset is lost biological activity >90% after 6 wash cycles. After 20 wash cycles, all bed nets lost >50% of insecticide concentration initially contained except Olyset. After 20 washes, Olyset were heated for 4 h at 60 0C to determine whether biological activity could be restored by heat assisted regeneration. Average mosquito mortality and knockdown in WHO cone tests for Olyset rising to >90% after heating for 4 h at 60 0C. However, regeneration of the biological activity of Olyset nets that had been washed three times did not occur at 30 0C or 35 0C after 12 weeks 19. Our research shows that heating routinely on permethrin treated LLINs could prevent malaria contagion in infants with odds ratio of 1.97 (CI 95%; 1.13 – 3.45) compared to that not using, not washing, not heating and not heating it routinely. As for not routine heat treating did not show significant association. Therefore to gain a better protection to malaria contagion a routine heating after LLINs washing is needed, which if the the heating is not routine so the effect is the same with not heating. Based on data from Pangkal Pinang Meterological Station, average temperature in Bangka District is varies between 26.20C to 28.30C. Apparently the average temperature is not enough to do spontaneous regeneration to increase insecticide biological activity as per Gimnig et al. 2005 19. However several researches had shown that Olyset was still maintain high biological activity after several washing cycles with no heat assisted

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regeneration. Vytilingham et al. 1996 is doing laboratory testing on comparation between Olyset to polyethylene monofilament and nylon multifilament blended with permethrin. The three bed nets is washed with water only and water and detergent. Test result after 15 washing cycles with water, mortality rate of Anopheles maculates was 95% for Olyset, 83% for nylon and 26% for polyethylene. Mortality rate for Aedes aegepty was 100% for Olyset, 91.7% for nylon and 81.7% for polyethylene. After 4 washing cycles with water and detergent mortality rate of Anopheles maculates was 86.7%, for Olyset, 80.3% for nylon and 3.33% for polyethylene. Mortality rate of Aedes aegepty was 90.3% Olyset, 50% for nylon and 5% for polyethylene 25. Inline with research by Jayalakshmi et al. (2006) which stated that Olyset was giving a better result compared to conventional ITN to 5 washing cycles (maximum bed nets utilization for conventional insecticide). Tami 2004 showed after 7 years of consecutive utilization in Tanzania, 90% of bed nets were still effective (CI 60 minutes > 95%) even mortality average was as low as 34%. Sharma 2009 stated that as a result of wash resistance and bio-efficacy of Olyset nets showed 100% mortality in An. culicifacies up to 11 washings, whereas 100% mortality was observed in An. fluviatilis even after 20 washings. The median knock-down time for these species ranged between 4.55-6.00 and 4.45-5.45 minutes, respectively, during 1 year of intervention 26. This research is a field research using case control study design. A few weaknesses is recognized such as bias presence and confounding variable which influencing research conclusion. Several covariate also calculated in model testing. From statistical analysis result showing that only one covariate significantly affecting, that is type of wall material, in which a concrete wall will provide a better protection to malaria compared to wooden wall. Sampling size is also having effect on research result. During the 1 year research is found 138 cases in intervention area. A longer duration is needed to gain an optimal sampling size that is 200 case for this research if CI is 95% and test authority of 80%. By all means information regarding laboratory testing and bioassay test is needed to prove difference in biological activity and insecticide concentration which contained in heated permethrin treated LLINs and not heated in field condition. ACKNOWLEDGMENTS We thank the people of Bangka District, District Health Service officers, and their local authorities for their excellent cooperation. We would also like to thank Ministry of Health of Indonesia for the support, Center for Disease Control and Prevention (CDC) and UNICEF for financial support. Lastly, a word of thanks to all the team members.

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REFERENCES 1. [MOH RI] Ministry of Health of Republik Indonesia. 2008. Indonesian Health Profile. Jakarta: MOH RI; 2007. 2. Newton CRJC. Cerebral malaria in children. 1996. J Child Neurol 11:257 3. Lines Jo. Severe malaria in children and transmission intensity. The Lancet 1997 3; 50: 813. 4. Fischer PR and Bialek R. Prevention of Malaria in Children. TRAVEL MEDICINE 2002; 34: 493-498. 5. Mathenge EM, Gimnig JE, Kolczak M, Ombok M, Irungu LW, Hawley WA. Effect of permethrin-impregnated mets on exiting behavior, blood feeding success, and time of feeding of malaria mosquitoes (Diptera: Culicidae) in Western Kenya. J. Med. Entomol. 2001; 38(4): 531-536. 6. Guillet P. Overview of LLIN Technologies. Meeting on Development, Production and Distribution of Long Lasting Insecticidal Nets (LLINs). Johannesburg, South Africa 23-24 September 2004. 7. Kulkarni M. Update on Long Lasting Insecticidal Nets (LLINs). Malaria Matters 2006; 15:1-2. 8. Shaw WD. Long-Lasting Insecticide Treated Nets: A Success In Technology Transfer. Malaria Matters 2006:15:3-4. 9. Coticelli P. WHOPES and Its Impact on Long-lasting Insecticidal Net Availability. Africa Fighting Malaria Occasional Paper. April 23, 2007. 10. N’Guessan R, Darriet F, Doannio JM, Chandre F & Carnevale P. Olyset Net efficacy against pyrethroid-resistant Anopheles gambiae and Culex quinquefasciatus after 3 years’ field use in Coˆ te d’Ivoire. Med Vet Entomol 2001; 15, 97–104. 11. Gimnig JE, Vulule JM, Lo TQ, Kamau L, Kolczak MS, PhillipsHoward PA, Mathenge EM, ter Kuile FO, Nahlen BL, Hightower AW, Hawley WA. Impact of permethrin-treated bed nets on entomologic indices in an area of intense year round malaria transmission. Am J Trop Med Hyg 2003; 68 (Suppl 4):16–22. 12. Tami A, Mubyazi G, Talbert A, Mshinda H, Duchon S, Lengeler C. Evaluation of OlysetTM insecticide-treated nets distributed seven years previously in Tanzania. Malaria J 2004; 3(19):1-9. 13. Dabiré RK, Diabaté A, Baldet T, Paré-Toé L, Guiguemdé RT, Ouédraogo JB and Skovmand O. Personal protection of long lasting insecticide-treated nets in areas of Anopheles gambiae s.s. resistance to pyrethroids. Malaria J 2006; 5(12):1-8.

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14. Sreehari U, Razdan RK, Mittal PK, Ansaria MA, Rizvi MMA, Dash AP. Impact of Olyset® Nets on malaria transmission in India. J Vect Borne Dis 2007; 44: 137–144. 15. Malima RC, Magesa SM, Tungu PK, Mwingira V, Magogo FS, Sudi W, Mosha FW, Curtis CF, Maxwell C, Rowland M. An experimental hut evaluation of Olyset® nets against Anopheline mosquitoes after seven years use in Tanzanian villages. Malaria J 2008; 7(38):1-8. 16. Hassan SEDH, Malik EFM, Okoued SI, Eltayeb ESM. Retention and efficacy of long-lasting insecticide-treated nets distributed in eastern Sudan: a two-step community-based study. Malaria J 2008; 7(85):1-6. 17. Sharma SK, Tyagi PK, Upadhyay AK, Haque MA, Mohanty SS, Raghavendra K, Dash AP.. Efficacy of permethrin treated long-lasting insecticidal nets on malaria transmission and observations on the perceived side effects, collateral benefits and human safety in a hyperendemic tribal area of Orissa, India. 2009; Acta Tropica 112: 181–187. 18. Sharma SK, Upadhyay AK, Haque MA, Tyagi PK, Mohanty SS, Raghavendra K, Dash AP. Field Evaluation of Olyset Nets: A LongLasting Insecticidal Net Against Malaria Vectors Anopheles culicifacies and Anopheles fluviatilis in a Hyperendemic Tribal Area of Orissa, India. J Med Entomol 2009; 46(2): 342-350. 19. Gimnig JE, Lindblade KA, Mount DL, Atieli FK, Crawford S, Wolkon A, Hawley WA. Dotson EM. Laboratory Wash Resistance of Longlasting Insecticidal Nets. Trop Med Int Health 2005; 10(10):1022– 1029. 20. Lindblade KA, Dotson EM, Hawley WA. Bayoh N, Williamson J, Mount D, Olang G, Vulule J, Slutsker L, Gimnig J. Evaluation of long-lasting Insecticide-treated bed nets after 2 years of household use. Trop Med Int Health 2005; 10 (11): 1141–1150. 21. [WHOPES] World Health Organization Pesticides Evaluation Scheme. Review of Olyset Net and Bifenthrin 10% WP. Report of the 5th WHOPES Working Group Meeting. 2001. WHO/CDS/WHOPES/2001.4. http://whqlibdoc.who.int/hq/2001/WHO_CDS_WHOPES_2001.4.pdf. 22. [BPS Kabupaten Bangka] Badan Pusat Statistik Kabupaten Bangka. 2007. Bangka Dalam Angka 2006. Bangka: BPS & BAPEDA Kab. Bangka. 23. Szklo M, Nieto EJ. Epidemiology Beyond the Basics. Maryland: An Aspen Publication; 2000. 24. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic Research, Principles and Quantitative Methods. New York: John Wiley & Sons. Inc.; 1982.

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25. Vythilingam I, Pascua BP dan Mahadevan S. Assessment of A New Type of Permethrin Impregnated Mosquito Net. Journal of Bioscience 1996; 7(1):63-70. 26. Jeyalakshmi T, Shanmugasundaram R, Murthy B. Comparative efficacy and Persistency of Permethrin in Olyset® Net and Conventionally Treated Net Againts Aedes Aegypti and Anopheles Stephensi. Journal of American Mosquito Control Association 2006; 22(1):107-110.