Middle East Respiratory Syndrome & Tantangan Global Health

Robertus Arian Datusanantyo

http://media.npr.org/

Pengantar

http://followtheoutbreak.files.wordpress.com/

I

Beberapa Outbreak

Tahun Nama Penyebab

1968 Hong Kong Flu Virus Influenza A subtipe H2N2

2003 Avian Influenza (AI)

Virus Influenza A subtipe H5N1

2003 Severe Acute Respiratory Syndrome (SARS)

SARS Coronavirus / SARS-CoV

2009 Swine Flu / Flu Babi

Virus Influenza A subtipe H1N1

2012 Middle East Respiratory Syndrome (MERS)

MERS Coronavirus / MERS-CoV

(Kasus Pertama di Inggris, seperti dilaporkan Pebody et al 2012)

(Dugaan penularan manusia ke manusia seperti yang dilaporkan The Health Protection Agency (HPA) UK Novel Coronavirus Investigation team 2013)

(Kasus pertama dan kedua dengan dugaan penularan manusia ke manusia di Perancis seperti dilaporkan Mailles et al 2013)

(Kasus Pertama di Jerman, seperti dilaporkan Buchholz et al 2013)

Keterlibatan Global

¨  Sejak April 2012, ada 536 kasus konfirmasi dengan 145 kematian (case fatality proportion 27,05%).

¨  Timur Tengah: Yordania, Kuwait, Oman, Qatar, Arab Saudi, Uni Emirat Arab, Yaman.

¨  Afrika: Mesir dan Tunisia. ¨  Eropa: Perancis, Jerman, Yunani, Italia, dan

Inggris. ¨  Lainnya: Malaysia Filipina, Amerika Serikat ¨  65,6% laki-laki, median usia: 49 tahun.

World Health Organization, 9 Mei 2014

Fakta-fakta Klinis

http://www.shevet.org/

II

Phylogenetic relationships among members of the subfamily Coronavirinae and taxonomic position of MERS-CoV.

de Groot R J et al. J. Virol. 2013;87:7790-7792

People Under Investigation (PUI) A.  Fever(≥38°C) and pneumonia or acute respiratory distress

syndrome (based on clinical or radiological evidence) AND EITHER:

A.  a history of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset, OR close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula OR

B.  a member of a cluster of patients with severe acute respiratory illness (e.g. fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being evaluated, in consultation with state and local health departments.

OR B.  Close contact with a confirmed or probable case of MERS

while the case was ill AND A.  fever (>100°F) or symptoms of respiratory illness within 14

days following the close contact. (CDC 2014)

Confirmed / Probable Case

¨  A confirmed case is a person with laboratory confirmation of MERS-CoV infection.

¨  A probable case is a PUI with absent or inconclusive laboratory results for MERS-CoV infection who is a close contact of a laboratory-confirmed MERS-CoV case.

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(CDC 2014)

Pencegahan ¨  Cuci tangan dengan sabun dan air

selama 20 detik. Dewasa / anak. Atau gunakan alcohol-based hand sanitizer.

¨  Tutup hidung dan mulut dengan tisu saat batuk / bersin, lalu buang tisu ke tempat sampah.

¨  Hindari menyentuh mata, hidung, dan mulut dengan tangan kotor.

¨  Hindari kontak personal: ciuman, berbagi alat makan / gelas, dengan orang sakit.

¨  Bersihkan & desinfeksi berkala permukaan barang yang sering disentuh, misal gagang pintu dan mainan.

Koleksi Pribadi

(CDC 2014)

Gambaran Klinis ¨  Gejala umum: demam, batuk, sesak

nafas. ¨  Spektrum lebar: dari asimtomatik

sampai multi organ failure dan kematian.

¨  Case fatality proportion 28-30% ¨  Saat MRS: demam, menggigil, sakit

kepala, batuk kering, sesak nafas, dan nyeri otot.

¨  Gejala lain: nyeri tenggorok, pilek, mual, muntah, dizziness, dahak, diare, dan nyeri perut.

¨  Perlu ICU: ISPA dengan progresi cepat ke pneumonia dalam seminggu.

http://ak4.picdn.net/

(CDC 2014)

Perjalanan Alamiah Penyakit

¨  Masa inkubasi transmisi antar manusia: 5 (2-13) hari. ¨  Pada MERS-CoV: onset sampai MRS 4 hari. ¨  Pada pasien kritis: onset sampai ICU 5 hari, median

onset sampai kematian 12 hari. ¨  Radiografis: peningkatan densitas atau opasitas, infiltrat

interstisial, konsolidasi, efusi pleura. ¨  Perburukan: gagal nafas akut, ARDS, hipoksemia

berulang, komplikasi ekstrapulmoner (AKI, hipotensi, hepatitis, syok septik).

¨  Laboratoris: leukopenia, limfopenia, thrombositopenia, dan kenaikan laktat dehidrogenase.

(CDC 2014)

A) Chest radiograph of a 61-year-old man, showing bilateral fine reticulonodular air-space opacities, increased vascular markings, and cardiomegaly. (B) Chest radiograph of an 83-year-old man, showing right lung consolidation, right basal pleural thickening, and reticulonodular air-space opacities; rib fractures on the right are old. (C) Chest radiograph of a 56-year-old man, showing extensive bilateral extensive diffuse and focal alveolar space opacities, with opacification of the left lower lobe. (D) Chest radiograph of a 67-year-old man, showing extensive bilateral disease, with diffuse alveolar space densities, opacification, reticulonodular opacities, and bronchial wall thickening. (E) Chest radiograph of a 49-year-old man, showing extensive bilateral mid and lower zone disease, with diffuse reticulonodular alveolar space opacities. A thoracic CT scan in the same patient (F) shows extensive bilateral opacities and ground-glass reticulonodular shadowing and bronchiolar wall thickening. (Assiri et al 2013)

Map of the Kingdom of Saudi Arabia showing the 2 study hospitals, the number of suspected and confirmed MERS-CoV infections in patients, and the number of HCWs screened and cases confirmed in HCWs. ICU 1 is located in Al-Ahsa and ICU 2 and ICU 3 in Riyadh. HCW = health care worker; ICU = intensive care unit; KAH = King Abdulaziz Hospital; KAMC = King Abdulaziz Medical City; MERS-CoV = Middle East respiratory syndrome coronavirus; UAE = United Arab Emirates.

Arabi et al 2014; Copyright © American College of Physicians. All rights reserved.

Study flow diagram. HCW = health care worker; ICU = intensive care unit; MERS-CoV = Middle East respiratory syndrome coronavirus. * Cases described in this report.

Arabi et al 2014; Copyright © American College of Physicians. All rights reserved.

Arabi et al 2014; Copyright © American College of Physicians. All rights reserved.

Arabi et al 2014; Copyright © American College of Physicians. All rights reserved.

Kesiapan Rumah Sakit

http://hill-kleerup.org/

III

Transmission Map of Outbreak of MERS-CoV Infection.

Assiri A et al. N Engl J Med 2013;369:407-416.

Penularan di Rumah Sakit

¨  Di Jeddah, >60% dari 128 kasus kemungkinan mendapat infeksi di rumah sakit (WHO, 2014).

¨  … jelas dari klaster yang berhubungan dengan pelayanan kesehatan, transmisi manusia ke manusia terjadi akibat paparan tanpa proteksi… (Arabi et al 2014).

http://images.thenews.com.pk

Penempatan Pasien

¨  Airborne Infection Isolation Room.

¨  Masker, single room dengan pintu tertutup.

¨  Filtrasi High-efficiency particulate air (HEPA)

¨  Batasi transportasi ¨  Batasi kontak, gunakan

APD http://www.mskcc.org/

(CDC 2014)

Kesiapan Petugas ¨  Alat perlindungan diri

¤  Gaun ¤  Masker N95 ¤  Kaca mata ¤  Sarung tangan

¨  Hand hygiene ¤  Cara cuci tangan ¤  5 moments in hand hygiene

¨  Edukasi keluarga / pengunjung

¨  Pembuangan limbah ¨  Penanganan linen

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(CDC 2014)

Global Health

http://hill-kleerup.org/ http://s.imwx.com/

IV

Beberapa Outbreak

Tahun Nama Penyebab

1968 Hong Kong Flu Virus Influenza A subtipe H2N2

2003 Avian Influenza (AI) Virus Influenza A subtipe H5N1

2003 Severe Acute Respiratory Syndrome (SARS)

SARS Coronavirus / SARS-CoV

2009 Swine Flu / Flu Babi Virus Influenza A subtipe H1N1

2012 Middle East Respiratory Syndrome (MERS)

MERS Coronavirus / MERS-CoV

Apa kesamaan dari kelima contoh outbreak pada slide

sebelumnya?

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Beberapa Ciri Serupa

¨  Penyakit baru, progresif, fatality rate tinggi. ¨  Menyebar cepat ¨  Melibatkan hewan (unggas, babi, kelelawar,

unta, dll) ¨  Dugaan kuat transmisi dari manusia ke

manusia ¨  Mempengaruhi pengambilan keputusan politis ¨  Berhubungan dengan kegiatan ekonomi global

Global Health

¨  An area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.

¨  Emphasizes transnational health issues, determinants, and solutions

¨  Involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration

¨  A synthesis of population-based prevention with individual-level clinical care

(Koplan et al 2014)

Global Health Geographical reach Focuses on issues that directly or

indirectly affect health but that can transcend national boundaries

Level of cooperation Development and implementation of solutions often requires global cooperation

Individuals or populations Embraces both prevention in populations and clinical care of individuals

Access to health Health equity among nations and for all people is a major objective

Range of disciplines Highly interdisciplinary and multidisciplinary within and beyond health sciences

(Koplan et al 2014)

International Health

(Koplan et al 2014)

Geographical reach Focuses on health issues of countries other than one’s own, especially those of low-income and middle-income

Level of cooperation Development and implementation of solutions usually requires binational cooperation

Individuals or populations Embraces both prevention in populations and clinical care of individuals

Access to health Seeks to help people of other nations

Range of disciplines Embraces a few disciplines but has not emphasized multidisciplinary

Public Health

(Koplan et al 2014)

Geographical reach Focuses on issues that affect the health of the population of a particular community or country

Level of cooperation Development and implementation of solutions does not usually require global cooperation

Individuals or populations Mainly focused on prevention programmes for populations

Access to health Health equity within a nation or community is a major objective

Range of disciplines Encourages multidisciplinary approaches, particularly within health sciences and with social sciences

Global Health vs Globalisasi

¨  Penyebaran risiko kesehatan / penyakit di dunia sering berhubungan dengan perdagangan atau usaha penguasaan.

¨  Peningkatan kecepatan komunikasi dan perjalanan, juga saling ketergantungan ekonomi antar bangsa, mengakibatkan timbulnya tingkat dan kecepatan saling keterhubungan baru yang disebut globalisasi.

¨  Global health menggunakan sumber daya, pengetahuan, dan pengalaman beragam bangsa untuk menjawab tantangan kesehatan di seluruh dunia.

(Koplan et al 2014) http://wardheernews.com

Infeksi: Faktor Berpengaruh The Microbial Agent The Human Host The Human Environment

Genetic adaptation and change Human susceptibility to infection

Climate and weather

Polymicrobial diseases Human demographics and behavior

Changing ecosystems

International trade and travel Economic development and land use

Intent to harm (bioterrorism) Technology and industry

Occupational exposures Poverty and social inequality

Inappropriate use of antibiotics Lack of public health services

Animal populations

War and famine

Lack of political will

(Morens & Fauci 2013)

http://www.dubaiairport.com/

http://cosmone.com/

http://images.dailystar-uk.co.uk/

Refleksi V

http://3.bp.blogspot.com/

Ringkasan

¨  MERS adalah penyakit infeksi baru yang berpotensi mengganggu global health.

¨  Sedikit yang telah diketahui namun banyak hal umum yang bisa diaplikasi.

¨  Sampai saat ini, Indonesia belum termasuk dalam daftar negara terlibat MERS.

¨  Indonesia, walau bagaimana, berpotensi BESAR terlibat dalam penularan MERS.

¨  Kita sebagai tenaga kesehatan tidak mungkin menghindari isu-isu global health, terutama soal infeksi (new-emergence maupun re-emergence).

Refleksi

¨  Apa yang telah saya pelajari dari pemaparan ini?

¨  Pengetahuan apa yang saya sudah tahu, dan pengetahuan baru mana yang saya dapat?

¨  Apakah pengetahuan baru ini mempunyai kontribusi pada diri saya?

¨  Bagaimana saya dapat berkontribusi pada masyarakat lewat pengetahuan ini?

¨  Pertanyaan apa yang saya harus cari jawabannya terkait pengetahuan baru ini?

Quiz - Berhadiah ¨  Berdasarkan pemaparan tadi dan refleksi yang anda

lakukan, buatlah tulisan sepanjang kurang dari 8 paragraf mengenai refleksi anda!

¨  Anda dapat menulis apa saja, dari sudut pandang mana saja. Semakin unik, semakin menarik.

¨  Quiz ini sukarela, tidak wajib. ¨  Attach tulisan via email ke arian9677@gmail.com

sebelum Rabu, 11 Juni 2014 tengah malam. Tuliskan pada subjek: “Refleksi MERS”.

¨  Tersedia hadiah menarik bagi dua tulisan terbaik. ¨  Tidak ada sponsor pada quiz ini.

Referensi

http://librosschmibros.files.wordpress.com/

VI

Referensi (1) ¨  Arabi YM; Arifi AA; Balkhy HH; Najm H; Aldawood AS; Ghabashi A; Hawa H; Alothman A;

Khaldi A; Raiy BA. Clinical Course and Outcomes of Critically Ill Patients With Middle East Respiratory Syndrome Coronavirus Infection. Ann Intern Med. 2014;160:389-397. Available online: http://annals.org/article.aspx?articleid=1817260

¨  Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A, Flemban H, Al-Nassir WN, Balkhy HH, Al-Hakeem RF, Makhdoom HQ, Zumla AI, Memish ZA. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect Dis 2013; 13: 752–61. Available online: http://dx.doi.org/10.1016/S1473-3099(13)70204-4

¨  Assiri A, McGeer A, Perl TM, Price CS, Al Rabeeah AA, Cummings DAT, Alabdullatif ZN, Assad M, Almulhim A, Makhdoom H, Madani H, Alhakeem R, Al-Tawfiq JA, Cotten M, Watson SJ, Kellam P, Zumla AI, Memish ZA. Hospital Outbreak of Middle East Respiratory Syndrome Coronavirus. N Engl J Med 2013;369:407-16. DOI: 10.1056/NEJMoa1306742. Available online: http://www.nejm.org/doi/full/10.1056/NEJMoa1306742

¨  Buchholz U, Müller MA, Nitsche A, Sanewski A, Wevering N, Bauer-Balci T, Bonin F, Drosten C, Schweiger B, Wolff T, Muth D, Meyer B, Buda S, Krause G, Schaade L, Haas W. Contact investigation of a case of human novel coronavirus infection treated in a German hospital, October-November 2012. Euro Surveill. 2013;18(8):pii=20406. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20406

Berikutnya…

Referensi (2) ¨  Centers for Disease Control and Prevention. Interim Infection Prevention and Control

Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV). Available Online: http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html

¨  Centers for Disease Control and Prevention. Middle East Respiratory Syndrome (MERS) Case Definitions. Available Online: http://www.cdc.gov/coronavirus/mers/case-def.html

¨  Centers for Disease Control and Prevention. Middle East Respiratory Syndrome (MERS) Clinical Features. Available Online: http://www.cdc.gov/coronavirus/mers/clinical-features.html

¨  Centers for Disease Control and Prevention. Middle East Respiratory Syndrome (MERS) Prevention and Treatment. Available Online: http://www.cdc.gov/coronavirus/MERS/about/prevention.html

¨  Centers for Disease Control and Prevention. Middle East Respiratory Syndrome (MERS) Symptoms and Complications. Available Online: http://www.cdc.gov/coronavirus/MERS/about/symptoms.html

¨  Groot RJ, Baker SC, Baric RS, Brown CS, Drosten C, Enjuanes L, Fouchier RAM, Galiano M, Gorbalenya AE, Memish ZA, Perlman S, Poon LLM, Snijder EJ, Stephens GM, Woo PCY, Zaki AM, Zambon M, Ziebuhr J. Middle East Respiratory Syndrome Coronavirus (MERS-CoV): Announcement of the Coronavirus Study Group. J. Virol. 2013, 87(14):7790. DOI: 10.1128/JVI.01244-13. Available online: http://jvi.asm.org/content/87/14/7790.full

Berikutnya…

Referensi (3) ¨  Koplan, JP, Bond, TC, Merson, MH, Reddy, KS, Rodriguez, MH, Sewankambo, NK, Wasserheit

JN. Towards a common definition of global health. Lancet 2009; 373: 1993–95. DOI:10.1016/S0140-6736(09)60332-9. Available Online: http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673609603329.pdf?id=aaaThPOBq3qThfUBjxWzu

¨  Mailles A, Blanckaert K, Chaud P, van der Werf S, Lina B, Caro V, Campese C, Guéry B, Prouvost H, Lemaire X, Paty MC, Haeghebaert S, Antoine D, Ettahar N, Noel H, Behillil S, Hendricx S, Manuguerra JC, Enouf V, La Ruche G, Semaille C, Coignard B, Lévy-Bruhl D, Weber F, Saura C, Che D, The investigation team. First cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infections in France, investigations and implications for the prevention of human-to-human transmission, France, May 2013. Euro Surveill. 2013;18(24):pii=20502. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20502

¨  Morens DM, Fauci AS. Emerging Infectious Diseases: Threats to Human Health and Global Stability. PLoS Pathog 2013:9(7): e1003467. DOI:10.1371/journal.ppat.1003467. Available Online: http://www.plospathogens.org/article/info%3Adoi%2F10.1371%2Fjournal.ppat.1003467

Berikutnya…

Referensi (4) ¨  Pebody RG, Chand MA, Thomas HL, Green HK, Boddington NL, Carvalho C, Brown CS,

Anderson SR, Rooney C, Crawley-Boevey E, Irwin DJ, Aarons E, Tong C, Newsholme W, Price N, Langrish C, Tucker D, Zhao H, Phin N, Crofts J, Bermingham A, Gilgunn-Jones E, Brown KE, Evans B, Catchpole M, Watson JM. The United Kingdom public health response to an imported laboratory confirmed case of a novel coronavirus in September 2012. Euro Surveill. 2012;17(40):pii=20292. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20292

¨  The Health Protection Agency (HPA) UK Novel Coronavirus Investigation team. Evidence of person-to-person transmission within a family cluster of novel coronavirus infections, United Kingdom, February 2013 . Euro Surveill. 2013;18(11):pii=20427. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20427

¨  World Health Organization. Middle East respiratory syndrome coronavirus (MERS‐CoV) summary and literature update–as of 9 May 2014. Available Online: http://www.who.int/csr/disease/coronavirus_infections/MERS_CoV_Update_09_May_2014.pdf?ua=1

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Koleksi Pribadi