Dr. Jarir Tadulako - June 2016

WELCOME
Jarir At Thobari, MD, MSc, DPharm, PhD
Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Tropical Disease - Treatment
Jarir At Thobari

S1 FK UGM, Medical Doctor
S2 New South Wales University (UNSW) Sydney, MMedSc
S2 Innsbruck University, Austria, (MSc in Pharmacology)
S3 Groningen University, The Netherlands (PhD in
Pharmacoepidemiology, Pharmacovigilance and Pharmacoeconomy)
Diploma in Molecular Epidemiology, Leeds University, United Kingdom
Diploma in Tropical Medicine, Institute Tropical Medicine (ITM),
Antwerpen, Belgium
Diploma in Vaccinology, Institute Pasteur, Paris, France
Diploma in Vaccinology, International Vaccine Institute (IVI), Seoul, Korea
Diploma in Advanced Vaccinology, Mereux Foundation, Annecy, France

Director of Clinical Epidemiology, Faculty of Medicine UGM & Sardjito
Hospital
Director Postgraduate Program of Medical Clinical Sciences, Fac Med. UGM
Senior Consutant for WHO Tropical Disease Research (WHO-TDR)
Senior Trainer Good Clinical Practice (GCP) for Regional WHO-SEARO
Trainer Good Health Research Practices (GHRP) for Regional WHO-SEARO
Expert Tim for HIV, Malaria and TB, Ministry of Health RI
Consultant of National Pharmacovigilance, BPOM, RI
Consultant of National Pharmacoeconomy and Health Technology
Assessment (HTA), Ministry of Health, RI
Secretary General, Indonesia Clinical Epidemiology Network

Tropical Disease Infections
Infectious diseases that either occur

uniquely or more commonly in tropical and
subtropical regions, are either more
widespread in the tropics or more difficult
to prevent or control.

Tropical and Subtropical Regions
350
230

Common Tropical Infectious Diseases in Indonesia
Leptospirosis Tuberculosis
Enteric fever Malaria
Typhoid fever Dengue infection
Paratyphoid fever Infective diarrhea
Helminthes infection

NTDs in poor populations
Previously
neglected Neglected tropical diseases
diseases TB
HIV/AIDS
Soil transmitted helminthiasis Anthrax
Schistosomiasis
Malaria Bovine tuberculosis
Lymphatic filariasis
Cysticercosis
Onchocerciasis
Leprosy Brucellosis
Trachoma
Leishmaniasis Echinococcosis
Zoonotic trypanosomiasis
Buruli ulcer
Chagas disease Rabies
Dengue
Neglected zoonoses

Global distribution of NTDs
~ 1 billion people have >1 NTDs

Session 1
TUBERCULOSIS

Risk of TB Infection

Classiying Tuberculin Skin Test (TST) Reaction
TST Induration Interpretation
5 mm induration Considered positive in:
HIV-infected individuals
Recent contacts of active TB case
Old healed TB
Transplant patients
Chronic liver or renal failure patients
Immunosuppressed patients

Foreign born from high TB endemic regions
IV drug abusers
Laboratory or health personnel
Staff and residents of high congregate settings
Children less than 5 years or active TB case in the family
All cases

Global Incidence of Tuberculosis
Zumla
Zumla A
Aet
et al.
al. N
N Engl
Engl JJ Med
Med 2013;368:745-755.
2013;368:745-755.
Anti TB Agents

Current recommendations for TB Treatment
Zumla
Zumla A
Aet
et al.
al. N
N Engl
Engl JJ Med
Med 2013;368:745-755.
2013;368:745-755.
Global Cases of MDR TB
Zumla
Zumla A
Aet
et al.
al. N
N Engl
Engl JJ Med
Med 2013;368:745-755.
2013;368:745-755.
MDR-TB Treatment & Related Toxicities
GROUP DRUGS COMMON TOXICITIES COMMENTS

First-line Agents Pyrazinamide Hepatotoxicity (<1% with WHO guidelines
Generally well (Pza) current dosing) recommend routine use
tolerated despite 50% - 70% MDR
Hyperuricemia and gout resistance rates in some
regions; reliable DST
Anorexia, vomiting
Ethambutol Central or peripheral retro No longer recommended
(Em) bulbar neuritis <1% cases for routine use in MDR-
TB treatment because
benefit not been shown

Injectable agents Aminoglycosides: Irreversible ototoxicity (6-18%) Parenteral administration

Kanamycin (Km) and in some cases may develop only
Amikacin (Amk) months after discontinuation
Km is preferred due to cost,
Nephrotoxicity - risk increased in but if resistance probable,
elderly, renal impairment, and use Cm should be used
with other nephrotoxic agents
Cross-resistance patterns
Cyclic polypeptide: are variable and complex -
Capreomycin (Cm) local drug choice often made
on basis of cost
and availability

Fluoroquinolones Moxifloxacin (Mfx) Generally well tolerated Optimal Mfx and Lfx doses
Levofloxacin (Lfx) not definitively established
Ofloxacin (Ofx) GI disturbance - nausea,
vomiting, diarrhea Ofx substantially less potent
Neurologic disturbance Use of ciprofloxacin is not

insomnia, restlessness; In less recommended
than 0.5%: agitation,
confusion, depression
Dose-related QT prolongation
common, so avoid use with long
Q-T syndrome and caution with
other drugs prolonging Q-T
interval

New Drugs for TB Treatment
Zumla
Zumla A
Aet
et al.
al. N
N Engl
Engl JJ Med
Med 2013;368:745-755.
2013;368:745-755.
Delamanid for MDR Pulmonary Tuberculosis
Proportion of Patients with
Sputum-Culture Conversion
by Day 57.
Gler
Gler MT
MT et
et al.
al. N
N Engl
Engl JJ Med
Med 2012;366:2151-2160.
2012;366:2151-2160.

MDR-TB T and Culture Conversion with Bedaquiline
Study Outcomes at 120 Weeks According

to the Protocol-Defined Analysis and an
Analysis Based on World Health
Organization Definitions.
Diacon
Diacon AH
AH et
et al.
al. N
N Engl
Engl JJ Med
Med 2014;371:723-732.
2014;371:723-732.

MDR-TB T and Culture Conversion with Bedaquiline
Diacon
Diacon AH
AH et
et al.
al. N
N Engl
Engl JJ Med
Med 2014;371:723-732.
2014;371:723-732.
Global TB Vaccine in Pipeline

Session 2
MALARIA

Global Burden of Malaria

Antimalarial Drug Activity in Life Cycle of
Plasmodia
preventing infection of
mosquitoes and
transmission of the disease
preventing primary or
secondary attacks
(relapses) of clinical
malaria
Baird
Baird JK.
JK. N
N Engl
Engl JJ Med
Med 2005;352:1565-1577.
2005;352:1565-1577.
Antimalarial Drug

Safety Antimalarial Drug
Baird
Baird JK.
JK. N
N Engl
Engl JJ Med
Med 2005;352:1565-1577.
2005;352:1565-1577.
Mutations in Plasmodium falciparum That Are
Associated with Resistance to Antimalarial Drugs

Session 3
DENGUE

Global Burden of Dengue

Immunopathogenesis Severe Dengue in Secondary
Infection

Hemorrhagic Manifestations of Dengue Infection.

Laboratory Diagnostic Options in a Patient with
Suspected Dengue Infection.

Vaccine Efficacy against Any Serotype of Dengue
Villar
Villar LL et
et al.
al. N
N Engl
Engl JJ Med
Med 2015;372:113-123.
2015;372:113-123.
Public health & economic impacts of
dengue vaccination in selected Indonesian
Local Government Units (LGU)
Model design Model calibration Simulations & analysis
Accuracy of the representation
Explicit assumptions Help decision making
Derive new hypotheses
Test new hypotheses Identify key drivers
Q : Do I capture Q : Is my model Q : What are the main

correctly disease consistent with conclusions and key
dynamics ? observed data ? drivers ?

Session 4
ROTAVIRUS INFECTION

CAUSES OF DEATHS IN CHILDREN
<5 YEARS
GLOBAL ASIA WHO SEARO
Others
Diare (19%)
(17%)
Perinatal
Pneumonia (31%)
(26%)
www.who.int.o
Bryce et al., 2005
WHO, 2004 rg

Diarrhea is the leading cause of death among
children under age five
Adapted from THE MILLENNIUM DEVELOPMENT GOALS REPORT, United Nations, 2014

Causes of death among baby and
children in Indonesia
Diarrhea is still becoming the leading cause of death among baby and children
Sourcer :Riskesdas 2007

Why is diarrhea dangeroys?
DIARRHEA DEATH due to LOST (& LACK) of:
WATER & ELECTROLYTE

FOOD
Dehydration death
malnutrition low Quality of life
Systemic ??
Diarrhea is a Threat to Childs Long Term
Development
Height Fitness I.Q.

Growth shortfalls of up Fitness impairment Repeated episodes of
to 8.2 cm by age 7 scores are diarrhoea in the first 2
years have been substantially reduced years of life can lead to
attributed to recurrent 46 years following a loss of IQ points2,3 and
episodes of diarrhoea recurrent episodes of an additional 12 months
during early childhood1 diarrhoea during early of schooling by age 9
childhood2 years

Distribution of Pathogen
Developed Countries Developing Countries
Parasites Unknown
Unknown Rotavirus Other Rotavirus
bacteria
Escherichia
coli
Bacteria Adenovirus Adenovirus
Astrovirus Calicivirus Astrovirus Calicivirus
From Kapikian AZ, Chanock RM. Rotaviruses. In: Fields Virology 3rd ed. Philadelphia,
PA: Lippincott-Raven; 1996:1659.

Rotavirus is a Major Cause of Child Mortality
Worldwide -- 453,000 Annual Deaths

Estimated Global Burden Rotavirus Infection
Risk of Particular Event Event
1 : 205 611,000 deaths
1 : 50 2.4 million inpatient visits
1:5 24 million
outpatient visits
1:1 114 million

domiciliary episodes
Rotavirus is said to be a democratic virus infecting all

children, rich or poor
Parashar, et al. Emerg Infect Dis 2006; 12(2):304306; Glass R et al. Lancet
2 2006; 368: 323332;
1 2
3 Glass RI et al. Acta Pediatr Suppl 1999; 88 (426): 2-8.

Disease Burden of Rotavirus in Indonesia
Children < 5 Years
Hospitalized children with diarrhea: 60% RV+
Outpatient children with diarrhea: 41% RV+ Deaths
10,651
Affects young children more: 72% 6-23 months Hospitalizations

209,970
RV+ diarrhoea: higher rates dehydration,

vomiting and death Clinic Visits
697,924
Total direct and indirect costs
= US$19.5 million/year
Episodes
4.8 million
Rotavirus Burden Indonesia Per Year

Damage caused by rotavirus

ROTAVIRUS DIARRHOEA IN HOSPITALISED
CHILDREN IN INDONESIA

Patient for Diarrhea & Rotavirus Diarrhea Among
Children U5 (Results Surveillance 2009)
Hospital # Enrolled Patients # RV+ (% to enrolled)
Sardjito Hospital, Yogyakarta 170 51 (30.0)
Hasan Sadikin Hospital,

294 133 (45.2)
Bandung
Sanglah Hospital, Bali 244 109 (44.7)
Mataram Hospital, Mataram 292 180 (61.6)
Total 1000 473 (47.3)

Five Lintas Diare

Rotavirus Vaccine

Europe1: ESPID and
ESPGHAN recommend
universal mass
vaccination of infants
against RVGE in
Europe Asia5: ASPID and
FHI recommend
universal mass
vaccination against
rotavirus in Asia
Latin America3,4
Australia2: PBAC
WHO-PAHO
recommends that the
recommends routine
two RV vaccines (HRV
RV vaccination in
and RV5) be funded
Latin America
under the national
immunisation
programme
HRV, human rotavirus vaccine; RV5, RVGE, rotavirus gastroenteritis
1. Vesikari et al. J Pediatr Gastroenterol Nutr 2008; 46: S38S48 (European Society for Paediatric Infectious Diseases
and European Society for Paediatric Gastroenterology, Hepatology and Nutrition Rotavirus Expert Group, 2008); 2.
Pharmaceutical Benefits Advisory Committee. 2007: http://www.health.gov.au [accessed Nov 2009]; 3. PAHO. 2007:
http://www.paho.org/English/AD/FCH/IM/IMBrochure_2007.pdf [accessed Aug 2009]; 4. WHO. Wkly Epidemiol Rec
2009; 84: 21336; 5. Asian Society for Pediatric Infectious Diseases and Family Health International:
http://www.fhi.org/NR/rdonlyres/e6gvmszrvc3sc63bk25ziy6axhx6yxpe4xwsy7w6nt4satv446m66ljw2nrrpaeluysgp64i
5rjhgb/ConsensusRotavirusMetaForum.pdf [accessed Jan 2009]

RV3 Phase IIb Clinical Trial
Safety, Immunogenicity & Efficacy Trial
Double blind randomized placebo controlled trial

3432 participants in Yogyakarta & Central Java

LONG STANDING COLLABORATION TRANSLATIONAL RESEARCH
1975 2000
Prof Y. Parasitolo Prof Iwan
Prof G. Barnes
Prof R. Bishop
Soenarto & gists: Dr Iskandar
Dwiprahasto
Prof J. Bines Prof.
Dr.T.Sebodo Nurhayati
Public
Prof J. Carlin Health:
Dr Nenny S
Prof A
Wilopo
Dr J. Buttery
Dr Jarir At Thobari
Microbiolo Dr IP Sukanto
gists:dr.T.
Dr M.Danchin H.Kesowo
M. Dr Cahya Dr A
DS Tholib
Danchi
Dr C. Kirkwood
n
Dr Bayu S, Dr Vicka O Dr Novilia Bachtiar

Dr J. Standish Dr Hera Nirwati
J.Standish
Ms E. Watts
dr. Icanervilia
dr. Rony Trilaksono
JUNIOR TEAM MEMBERS (RESEARCH ASSISTANTS)
2012 2013 2014
Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM 2015

THANK YOU

ANTIBIOTICS & POLICY
Jarir At Thobari

Antibiotics
One of the most commonly used group of drugs
In USA 23 million kg used annually; 50% for
medical reasons
May account for up to 50% of a hospitals drug
expenditure
Studies worldwide has shown a high incidence
of inappropriate use

Prescribing an antibiotic
Is an antibiotic necessary ?
What is the most appropriate antibiotic ?
What dose, frequency, route and duration ?
Is the treatment effective ?

Useful only for the treatment of bacterial
infections
Not all fevers are due to infection
Not all infections are due to bacteria
There is no evidence that antibiotics will
prevent secondary bacterial infection in
patients with viral infection

Arroll and Kenealy, Antibiotics for the common cold.
Cochrane Database of Systematic Reviews. Issue 4, 2003
Meta-analysis of 9 randomised placebo controlled

trials involving 2249 patients
Conclusions: There is not enough evidence of

important benefits from the treatment of upper
respiratory tract infections with antibiotics and there
is a significant increase in adverse effects
associated with antibiotic use.

cough, bronchitis, sputum, and respiratory tract

infections.
RCT, from 1966 -1998
Antibiotic is nor more good than placebo if cough resolution

is measured at 7-11 days RR= 0.85 (95% CI 0.73 to 1.00)
Antibiotic is not significantly influence the cure rate (RR=

0.62; 95%CI:0.36 to 1.09
Side effect of AB: 19% (12-36%); RR = 1,9 (1,19-3,21)

Inappropriate Antibiotic prescribing
Amoxicillin mg 250
Paracetamol tab
Dexamethasone tab
GG tab
Phenobarbiton mg 30
Vitamin C mg 20
Mfla dtd no. XII S 3dd I
Infant, 7 months with ARI

Indonesian puyer: pulverizing 2 or
more (often 5-10) drugs into a powder
and then allocating doses by eye

Inappropriate use of AB in ARI

Use of antibiotics for ARI in children/adult patients visiting
primary health centres - East Java Province (%)

ARI treatment indicators over time, including only
studies of medicines use in children < 5 years with ARI

Choice of an antibiotic
Aetiological agent
Patient factors
Antibiotic factors

The aetiological agent
Clinical diagnosis
clinical acumen
the most likely site/source of infection
the most likely pathogens
empirical therapy
universal data
local data

Importance of local antibiotic resistance data
Resistance patterns vary

From country to country
From hospital to hospital in the same country
From unit to unit in the same hospital
Regional/Country data useful only for
looking at trends NOT guide empirical
therapy

Patient factors
Age
Physiological functions
Genetic factors
Pregnancy
Site and severity of infection
Allergy

Antibiotic factors
Pharmacokinetic/pharmacodynamic (PK/PD)
profile
absorption
excretion
tissue levels
peak levels, AUC, Time above MIC
Toxicity and other adverse effects
Drug-drug interactions
Cost

PK/PD Parameters
Increasing knowledge on the association
between PK/PD parameters on clinical
efficacy and preventing emergence of
resistance
Enabled doctors to optimise dosage
regimens
Led to redefinition of interpretative
breakpoints in sensitivity testing

ImportantPK/PD
Important PK/PDParameters
Parameters
Time above MIC : 8
Antibiotic concentration (ug/ml)

Proportion of the
6
dosing interval Drug A
Drug A
when the drug 4 Drug B
Drug B
concentration
exceeds the MIC 2
B
B
0
A Time
Time above MIC

Important PK/PD Parameters
Area under the curve

AUC/MIC is the over MIC
concentration
ratio of the AUC
Antibiotic
PEAK
to MIC
Peak/MIC is the
ratio of the peak MIC
concentration to
MIC
Time

PK/PD and Antimicrobial Efficacy
2 main patterns of bacterial killing
Concentration dependent
Aminoglycosides, quinolones, macrolides, azalides, clindamycin,
tetracyclines, glycopeptides, oxazolidinones
Correlated with AUC/MIC , Peak/MIC
Time dependent with no persistent effect

Betalactams
Correlated with Time above MIC (T>MIC)

Goal of therapy based on PK/PD
Pattern of Activity Antimicrobials Goal of therapy and relevant
PK/PD Parameter
Concentration dependent killing AMGs, Quinolones, Daptomycin, Maximise concentrations;

ketolides, Macrolides, azithro- AUC/MIC, peak/MIC
mycin, clindamycin, Use high doses; daily dosing
streptogramines, tetracyclines, for some agents
glycopeptides, oxazolidinones
Time dependent killing with no Betalactams Maximise duration of

persistent effects exposure; T>MIC
Use more frequent dosing;
longer infusion times
including continuous infusion

Incorrect frequency & route of AB treatment
Ampicillin
Ampicillin 33 times/day
times/day
Tetracycline
Tetracycline 33 times/day
times/day
Erythromycin
Erythromycin33 times/day
times/day
Taking
Taking ampicillin
ampicillin with
with food
food
Sugar
Sugar coated
coated is
is crushed
crushed

Antibiotic concentration in blood
Antibiotic concentration in blood after its given

regularly every 8 hours
Cmax
MTC
Therapeutic Level
MIC
07.00 15.00 23.00 07.00

Time antibiotic is taken

Antibiotic concentration in blood pemberian after its given three
Antibiotic concentration in blood
times per day
Cmax
MTC
No drug
in blood
MIC
7 1300 15 1900 23 700

Time antibiotic is taken

Cost of antibiotic
Not just the unit cost of the antibiotic

Materials for administration of drug
Labour costs
Expected duration of stay in hospital
Cost of monitoring levels
Expected compliance

Ciproxin 500 mg X Rp 289.200,-
Ponstan 250 mg XV Rp 18.700,-
Immunos VII Rp 43.900,-
Max C 500 mg VII Rp 18.899,-
Value Rp 370.600,-
Baquinor 500 mg X Rp 128.700,-
Pondex 250 mg XV Rp 7.100,-
Max C 500 mg VII Rp
18.800,-
Value Rp 198.500,-
Ciprofloxacin 500 mg X Rp
15.400,-
Mefenamic ac. 250 mg XV Rp
3.000,-
Max C 500 mg VII Rp
18.800,-
Department of Pharmacology & Pharmacotherapy,
Value Rp 81.100,- Fac. Medicine UGM
Choice of regimen
Oral vs parenteral
Traditional view
serious = parenteral
previous lack of broad spectrum oral antibiotics with
reliable bioavailability
Improved oral agents
higher and more persistent serum and tissue levels
for certain infections as good as parenteral

Advantages of oral treatment
Eliminates risks of complications
associated with intravascular lines
Shorter duration of hospital stay
Savings in nursing time
Savings in overall costs

Duration of treatment
In most instances the optimum duration is
unknown
Duration varies from a single dose to
many months depending on the infection
Shorter durations, higher doses
For certain infections a minimum duration
is recommended

Recommended minimum durations of
treatment
Infection Minimum duration

Tuberculosis 4 - 6 months
Empyema/lung abscess 4 - 6 weeks
Endocarditis 4 weeks
Osteomyelitis 4 weeks
Atypical pneumonia 2 - 3 weeks
Pneumococcal meningitis 7 days
Pneumococcal 5 days
pneumonia

Monitoring efficacy
Early review of response
Routine early review
Increasing or decreasing the level of
treatment depending on response
change route
change dose
change spectrum of antibacterial activity
stopping antibiotic

Cotri tab no. 3
Metro tab no. 3
Vit K tab no. 3
Diaform tabno. 3
Mf pulf dtd X
S 3 dd 1
NL, 3 years old with diarrhea

The Effect of Irrational Use
of Antibiotics
Adverse Drug Effect Incompliance
Resistensi Not cured

Irrational Use of Antibiotic as risk factor
mortality in ICU
Hospital mortality (%) Inappropriate therapy Appropriate therapy

60 p<0.001
p<0.001
50
40
30
20
10
0
All causes Infectious disease-related
Kollef et al. Chest 1999;115:462474
Mortality type
Relation between Antibiotic Use and
Resistance

Overuse and misuse of antimicrobials contributes
to antimicrobial resistance
Malaria
choroquine resistance in 81/92 countries
Tuberculosis
2 - 40 % primary multi-drug resistance
Gonorrhoea
5 - 98 % penicillin resistance in N. gonorrhoeae
Pneumonia and bacterial meningitis
12 - 55 % penicillin resistance in S. pneumoniae
Diarrhoea: shigellosis
10-90+ % amp, 5-95% TMP/SMZ resistance
WHO, Dept. Essential Drugs and Medicines Policy
Department of Pharmacology & Pharmacotherapy,

Source: Fac.
DAP, EMC, GTB, CHD Medicine UGM
(1997)
Fluoroquinolone Use and Resistance
Rates of Gram-negative Bacilli

Bacterial resistant for AB
No evidence due to bacterial infection

Choose inappropriate antibiotics
Dosage (over or under)
Given for long period
Prophylactic antibiotics
inappropriate self-medication.

Prophylactic Antibiotic
Pre & post Surgery ?
Principle: tissue concentration

Single dose
High dose
Before surgery procedure
Can be repeated for long surgery
Within 24 hrs

Timing Prophylactic Antibiotics

Combination Antibiotic
Severe/serious infection
Multiple organism
Synergism
Reduce or prevent bacterial resistant
Single is more toxic
Penicillin + gentamicin vs. streptococci

Ticarcillin + gentamicin vs. Ps. Aeruginosa
Cephalosporin + aminoglicosides vs. Klebsiella pneumon

Why is irrational?
Inadequate training
Lack of continuing education &
supervision
Promotional activities
Lack of time due to heavy patient load
Pressure from patient
Fear-induced prescription

Guideline Adherence

Rational use of Antibiotics
Diagnosis Follow up
Indication Appropriate Patients
Drug(s) Information
Dose, route, treatment course

Many Factors Influence
Use of Medicines
Prior Knowledge Intrinsic
Scientific
Habits
Information Information
Influence Social &

of Drug Cultural
Industry Treatment Factors
Societal
Workload &
Choices Economic &
Staffing Legal Factors
Workplace Infra- Authority &

structure Relationships Supervision
With Peers
Workgroup

Antibiotic Resistance:
Key Prevention Strategies
Susceptible Pathogen
Antimicrobial-Resistant
Pathogen Pathogen
Prevent Prevent
Transmission Infection
Infection
Antimicrobial
Resistance
Effective
Optimize Diagnosis
Use & Treatment
Antimicrobial Use
Prevent Antimicrobial Resiatnce
12 Break the chain

11 Isolate the pathogen Prevent Transmission
10 Stop treatment when cured
9 Know when to say no to van
Use Antimicrobials Wisely
8 Treat infection, not colonization
7 Treat infection, not contamination
6 Use local data
5 Practice antimicrobial control
4 Access the experts Diagnose & Treat Effectively
3 Target the pathogen
2 Get the catheters out Prevent Infections
1 Vaccinate

Hospital Antibiotic Policy
To provide the most effective and empirical
treatment for individual patient with minimal
adverse reactions.
To motivate the rational use of antibiotics
To prevent the development of drug resistance by
judicious and timely use of relevant antibiotics.
Cost effective and rational use of drugs for
treatment.

Hospital Antibiotic policy
Educational programs designed to improve antibiotic
uses.
Controls operated through the Pharmacy department.
Creation of hospital pharmacopeia.
Written justification for the costlier and broader
spectrum of antibiotics.
Introduction of concept of stop orders
Sponsoring of antibiotics according to their usage e.g.
prophylaxis, specific therapy, therapeutic trials etc.

Antibiotic policy
Controls through the laboratory in the form of
reporting, regular issue of resistance/susceptibility
patterns and active consultations.
Establishment of an antibiotic advisory service in the
hospital.
Publication of consensual antibiotic policy for special
use e.g. prophylaxis and specialized clinical units.

DANGEROUS PRODUCT &
NARCOTIC
Jarir At Thobari

Session 1
CIGARETTE

Global perspektif
Cigarettes
Consumption
konsumsi 6 trilyun rokok per tahun

China, India dan Indonesia tobaco use meningkat
Global Deaths
Saat ini:
5 juta
kematian/tahun
13,400 orang/hari
560 orang/jam
Satu/6 detik
2030:
10 juta kematian
akibat penggunaan
tobacco
70% negara
berkembang
Indonesia juara ke
3

Tobacco Consumption in South East Asia

Cigarette consumption in Indonesia
An increase of 500% in 35 years
Department
WHO, 2008 of Pharmacology & Pharmacotherapy, Fac. Medicine UGM
Cigarette consumption in Indonesia
Pada tahun 2008 meningkat menjadi 230 milyar batang.

Pada tahun 2004, rata-rata konsumsi rokok adalah 11 batang perorang
perhari (laki-laki : 11 batang/hr, wanita : 10 batang/hr). (TCSCIAKMI,
SEATCA , WHO, 2007; WHO, 2008)

Perokok di Indonesia
Lebih dari separuh (57%) rumah tangga di

Indonesia mempunyai sedikitnya satu orang
perokok dan hampir semua perokok (91,8%)
merokok di rumah
Data terakhir menunjukkan total perokok aktif di

Indonesia mencapai 70% dari total penduduk,
atau 141,44 juta orang dan 30% nya berasal
dari ekonomi lemah

Prevalensi Smoking di Indonesia
YES
NO
YES
(63.5%) NO
(96.7%)
Permulaan merokok: 25% anak usia 10 tahun

65% anak dan remaja terpapar second hand smoke
di rumah
(CDC, 2008)

Perokok Pasif di Indonesia
66 % wanita Indonesia merupakan perokok pasif

.70 % anak usia 10 14 tahun merupakan perokok
pasif
64,2 % pelajar terpapar asap rokok di rumah

81 % pelajar terpapar asap rokok di tempat umum

Anak dan remaja terpapar rokok pasif
di rumah

Second Hand Smoke (SHS)
SHS sangat berbahaya

SHS dapat menyebabkan penyakit pada anak
dan dewasa, termasuk:
Penyakit jantung koroner
Kanker paru
Infeksi telinga
Asma
Sudden Infant Death Syndrome
Tidak ada kadar yang aman
untuk SHS
(USSGR, 2006)

Bangkok, Thailand, February 2006

Air Quality Index

Anak dan remaja terpapar rokok pasif di
rumah

Rokok menyebabkan kerugian pada
hampir seluruh organ tubuh
WHO, 2008
Rokok sebagai risiko Tuberkulosis
Smokers vs. non smokers
TB Infection 2.0 vs. 1.0
TB Disease 3.0 vs. 1.0
TB Mortality 1.5 vs. 1.0
(Bates et al., 2007)

Rokok dan infeksi saluran
pernafasan
Perubahan struktur
inflamasi dan fibrosis pada peribronchiolar
Kerusakan pada sel epitel salurna nafas
Saluran lebih rentan mudah terinfeksi
Mekanisme imunologis
Penurunan kekebalan tubuh dan sirkulasi
imunoglobulin
CD4 lymphopenia, CD8+ lympocyte counts
depressed phagocyte activity, and decreased
release of proinflammatory cytokines.
(Arcavi and Benowitz, 2004)

Merokok pada pasien TBC di
Indonesia

Passive smoking dan
tuberculosis
passive vs. non-passive = 3.3 kali vs. 1.0

anak > dewasa
jumlah rokok yang dikonsumsi keluarga
jumlah kontak dengan perokok
(Lin et al., 2007)

Rokok dan Penyakit Paru Obstruksi
Menahun (PPOM)
inflamasi pada paru
peningkatan produksi mukus
Bronkhitis (40%)
penurunan fungsi paru (PPOM) (25%)
hospitalisasi dan kematian

Passive smoking dan PPOM
Paparan SHS yang besar di tempat kerja atau rumah,
meningkatkan PPOM sebesar 50%
Di China, 12% kematian pada pasien non-smoker adalah

akibat PPOM
Dari sekitar 2 juta kematian PPOM, separuhnya

diperkirakan terjadi pada non-smoker yang terpapar SHS
(>5 tahun dengan 40 jam papapran per minggu)
(Yin et al., 2007)

Emphysema
Normal Lung Emphysema

Rokok dan Asthma
inflamasi & Ashtma
immunologis Bronchiale
proses

Efek Smoking pada Diabetes
Makro-mikro Endothelial Resistensi Hipoksia

vaskular Dysfunction insulin Jaringan
CVD
Neuropathy
Retinopathy
Nephropathy

Gangrene and Amputation

Rokok dan kanker oral
Kanker oral
Merokok meningkatkan risiko kanker oral
sebanyak 1000% sampai 2000%
Risiko meningkat sejalan dengan jumlah
dan lama merokok
Leukoplakia
Lesi prekanker
6 kali lebih sering pada perokok
US surgeon Generals Report, 2004; Primary Care: 26(3);463-98, 1999

Early squamous cell carcinoma Early oral cancer
leukoplakia leukoplakia

Kondisi Oral Lainnya
Acute Necrotizing Ulcerative Periodontal disease

Gingivitis (periodontal disease) with gum recession
karang gigi Pewarnaan akibat rokok

Merokok dan Impotensi
Risiko yang paralel dan kuat dengan Penyakit

jantung koroner & Atherosclerosis
Risiko impotensi meningkat seiring

dengan jumlah dan durasi merokok
Sebagian disebabkan oleh kerusakan

fungsi normal dinding pembuluh darah

Merokok dan Impotensi
Penelitian Massachusetts
513 laki-laki tanpa impotensi,
diabetes atau penyakit jantung (8
tahun)
Perokok aktif 90% risiko lebih tinggi

Perokok pasif 240% risiko lebih tinggi
Perokok cerutu - 200% risiko lebih
tinggi

Merokok dan penyakit
mata
Katarak
(230%)
Setiap durasi > 10
tahun katarak
meningkat >20%

Merokok dan Sistem Imunitas
Penurunan jumlah
dan fungsi sel
imun
Penurunan
antibodi
Psychoneuroendocrinology 198;23:175-187

Merokok dan Psikiatrik
Angka merokok lebih tinggi pada

semua kelompok penderita gangguan
jiwa dibandingkan dengan populasi
umum
Depresi Schizophre Gangguan

mayor nia bipolar
(20-40 %) (70-90%) (>50%)

SHS dan Anak-Anak
Anak > sensitif terhadap asap rokok
Bapak perokok
ISPA > 30%,

Batuk 10-30%
Asthma 20-30% (<6 th), 5-20% (>6 th)
Infeksi telinga 60%
Sudden Infant Death Syndrome 50-200%
Hospitalisasi > 30%

Apakah anak kita akan memiliki
masa depan yang bebas rokok?
Rokok dan Kehamilan
CO, terikat secara irreversibel pada
hemoglobin fetus shg penurunan
pengangkutan oksigen kepada fetus
Nikotin menurunkan aliran darah

uterus sampai 38%
Toksin dalam asap dapat melewati

plasenta

Efek Asap Rokok Terhadap Janin
Karbon Monoksida
Mengakibatkan penurunan pengangkutan
oksigen kepada janin pertumbuhan janin
terganggu.
Nikotin
Menurunkan aliran darah ke rahim sampai 38%
pertumbuhan janin terganggu.
Racun dalam asap dapat masuk ke tubuh janin.

SHS dan Kehamilan
BBLR 240%
Kelahiran prematur 600%
Kelahiran sangat prematur 530%
Beberapa penelitian menunjukkan bahwa
menjadi perokok pasif meningkatkan risiko
keguguran dan kelainan janin.
Hruba D. Cent. European J Health, 2000; Dejmek J. Environ. Health Perspect. 2002;
Windham GC. Paediatric and Perinatal Epi. 1999; Ahluwalia IB. Am J Epi 1997.

SHS dan penyakit pada
dewasa
Kanker pada perokok pasif
Rokok biasa kanker paru >280%
Rokok kretek kanker paru > 300%
Asma terpapar perokok pasif:
Batuk - 20% risiko lebih tinggi
Dyspnea 85% risiko lebih tinggi
Keberbatasan aktifitas - 200% risiko
lebih tinggi
Taufik, 2000;
Cigarettes-drugs interaction
Kinetic Dynamic
Trycyclic Benzodiazepine
antidepressant
(diazepam)
Insulin
Beta blockers
Heparin
Alprazolam Hormonal
Chlorpromazine contraceptives
Haloperidol Inhaled
Theophylline corticosteroid
Opioids

Cigarettes-drugs interaction

Health benefits after quitting
Exercise tolerance improves rapidly

Bladder cancer: 50% reduction in 5 yrs
Lung cancer: 50% reduction in 10 yrs
Heart disease: 50% reduction in 1 yr
No excess risk of heart disease by 10-15 yrs
Vascular disease: 50% reduction in 5 yrs
Mortality, same as never smokers by 10-15
yrs

Non-health reasons for quitting
Costs
Inconvenience
self-esteem
role model

Common concerns
Withdrawal
short lived
Cravings
last 3-5 minutes, diminish rapidly
Tension
validate, normalize
find other ways to cope
Weight gain - not inevitable!
1/3 gain: 5-8 lbs.

Withdrawal Symptoms
Anxiety 87%
Irritability, Frustration, Anger 87%
Heart Rate 80%
Difficulty Concentrating 73%
Appetite and Weight Gain 73%
Restlessness 71%
Craving for Cigarettes 62%
Depression , Dysphoria 31%
Severity Withdrawal Symptoms
10
9
8
7
Withdrawal
6
Symptom Symptom severity while smoking
5
severity
4
3
2
1
0
0 2 4 6 8 10 12
Weeks since stopping smoking

Session 2
NARCOTICS &
PSYCHOTROPIC DRUGS
Over-the-Counter Drugs
DXM
3.1 million 12-25 yr olds used
Dextromethorphan products to
get high the last year

Narcotic & dangerous drugs
Any variety of substances inducing altered
states of consciousness...
And derived from the opium poppy
Legally, Narcotics is designated as any
drug that is
allegedly dangerous
heavily abused

Narcotic & dangerous drugs
In general, it is considered any drug that

produces a stupor, insensibility or sleep

Opiates
Any of the narcotic

drugs produced from
the opium poppy

Drug abuse
Chronic use leads to physical and
psychological dependence
Categories
Narcotics
Stimulants
Sedatives
Hallucinogens

Narcotics
Depressant effect on nervous system
Euphoria, feeling of warmth and well-being
Used to relieve pain, induce sleep
Tolerance to dose levels requires increased
dosages for same effect

Types of narcotics
Heroin
Cocaine
Morphine (eq. Codein)
Percodan (eq. methadone)

Heroin
An odorless, crystalline, white powder
Acts as a depressant to spinal cord
Tolerance to dosage is fast
Danger of drug dependency
Is cut with various substances to reduce potency,
extend profit
Street dealers cut or step on drug prior to
sale Considerable profit

Cocaine
Made from the coca plant
White, odorless, crystalline
powder
Medically used for operations
on ear, eye, nose
Illicit cocaine - cut with sugar
and local anesthetics
stimulates central nervous
system, increases heart rate

Freebasing cocaine
Separation of base cocaine
from its hydrochloride powder
Once separated, crystals are
smoked - produces a more
potent high

Crack Cocaine
Converts its base state without
removing any adulterants
Looks like chalky rock

Morphine
A condensed extract of opium
More potent
White
Powder
Cubes
Tablets

Codeine
Alkaloid codeine found in crude opium or
produced synthetically
Least addictive of opium derivatives
Fine, white crystalline powder
Can be found in a number of legally
provided medical preparations
Used by addicts - substitute for heroine or
morphine

Percodan
Important medicine as a pain killer
Closer to morphine in its effects
Taken orally, or dissolved in water and
injected

Methadone
Produced as a response to a shortage of
morphine during World War II
Produces much the same effects as
morphine or codeine
Can be administered orally or
intravenously
Withdrawal symptoms are milder and
occur more slowly

Stimulants
Non-narcotic, directly stimulates the
central nervous system
Increases activity of tissues (central
nervous system)
Affects the physiological processes of the
body
Produce zest, excitement
Produce a state of euphoria and energy

Sedatives
Used to allay irritation or nervousness
Creates a lethargic, sleepy feeling
Effect of calm, well-being

Depressants
Sedatives
Hypnotics
Frequently prescribed to induce sleep
Can be legally purchased with a
prescription
Overdose (with alcohol) can result in
unconsciousness or death

Transquilizer
Originally developed as medical aids to
psychotherapy for mental patients
Valium, Librium- prescribed for anxiety,
antidepressants.

Halucinogens
Capable of altering perceptions and producing
hallucinations
Perceptions of heightened senses and vivid
colors
Produce exaggerated feelings of terror, visions of
monsters, terrifying imagined situations
Sometimes produce flashbacks, images and
states of mind

LSD
One of most powerful drugs abused on the
market
Administered orally, often placed on a sugar cube
in a drink, or on a blotter
Average dose- a tiny speck on
a toothpick, 30 or 40 micrograms
Causes mental and perceptual changes
No physical dependence, not addictive

PCP (Phencyclidine)
Originally an animal tranquilizer and
anesthetic
May function as a stimulant, depressant or
analgesic

Mascaline
Used by Native Americans in religious
rituals
Buttons from cactus ground into a powder,
bitter- mixed with juice, coffee ,etc
Also a powder in capsules or liquid

Cannabis
A mild hallucinogen
A widely abused drug
Grows worldwide
Marijuana, hashish, hash oil

Psilocybin & Psilocyn
Magic Mushrooms
Psilocybe species
Used in Indian rites for centuries


Designer drugs
Substances produced in
clandestine laboratories
Add or take away
something in an existing
drugs composition

Inhalants
Not part of illicit drug trade

Serious problem for law
enforcement
Household solvents, cleaners,
aerosols used to obtain a high
Gasoline, paint, Freon, model
airplane glue, amyl or butyl
nitrate
Snappers or Poppers

THANK YOU

TRAVELLERS HEALTH
Jarir At Thobari

http://wwwnc.cdc.gov/travel
http://www.who.int/ith/en/

World Flight Tracking (08/06/2015)

Indonesia Flight Tracking (08/06/2015)

2014 Ebola Outbreak
Reported
Reported Cases
Cases (Suspected,
(Suspected, Probable, and
and Confirmed)
Confirmed) in Guinea, Liberia,
and
and Sierra
Sierra Leone
Leone
This graph shows the total reported cases (suspected, probable, and confirmed) in Guinea, Liberia,
and Sierra Leone provided in WHO situation reports beginning on March 25, 2014, through the most
recent situation report on June 3, 2015.

EVD Cases and Deaths*
Total Cases
(Suspected,
Reporting Date Confirmed Cases Total Deaths
Probable, and
Confirmed)
Guinea 4 June 15 3,657 3,227 2,431
Liberia** 9 May 15 10,666 3,151 4,806
Sierra Leone 4 June 15 12,850 8,623 3,912
Italy 20 May 15 1 1 0
United Kingdom*** 29 Dec 14 1 1 0
Nigeria*** 15 Oct 14 20 19 8
Spain*** 27 Oct 14 1 1 0
Senegal*** 15 Oct 14 1 1 0
United States*** 24 Oct 14 4 4 1
Mali*** 23 Nov 14 8 7 6
TOTAL 27,076 15,010 11,155
Updated case counts available at http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html.

* Total cases include probable, suspected, and confirmed cases. Reported by WHO using data from ministries of health
**One case of Ebola was confirmed on March 20, 2015. No cases of Ebola were identified during 21 days of monitoring of contacts of this case. WHO
declared the end of the Ebola outbreak in Liberia on May 9, 2015, after 42 days (two incubation periods) had passed since the last Ebola patient was
buried. Public health authorities are maintaining active surveillance so that any new cases of Ebola are rapidly identified.
***There are currently no Ebola cases in Senegal, Nigeria, Spain, the United States, the United Kingdom, and Mali.

What Is Middle East Respiratory Syndrome (MERS)?
Middle East Respiratory Syndrome (MERS) is

a viral respiratory illness.
MERS is caused by a coronavirus called

Middle East Respiratory Syndrome
Coronavirus.
MERS-CoV was first reported in 2012 in Saudi

Arabia.
Source: NBC News

Where Did MERS - CoV Come From
At this time, it is unclear where the virus developed.
MERS-CoV most likely came from an animal

source.
In addition to humans, it has been found in camels in

Qatar, Egypt and Saudi Arabia, and in a bat in Saudi
Arabia. (CDC)
Camels in a few other countries have also tested

positive for antibodies to MERS-CoV which means
they were previously infected with MERS-CoV or a
closely related virus.

How Is MERS-CoV Transmitted
MERS-CoV is transmitted by water droplets that
are expelled from the lungs when a person
breathes, coughs or sneezes.
MERS-CoV has been shown to be transmitted by

close contact with a person who is infected with
the virus.
A close contact to the ill person includes:

Health care provider providing care to an ill patient.
Family member who is taking care of the ill person at
home.
Anyone who visited the person when the person was ill.
A person who has traveled with the ill person within the
past 14 days.

Am I At Risk For Developing
MERS-CoV...
The groups at highest risk for developing
MERS-CoV are:
Infants/Children
Elderly
People with immune system problems
Chronic Heart, Lung and Kidney problems
Pregnant women
People with Diabetes
A person who has traveled to one of the

locations that has had confirmed lab tests
that are positive for MERS-CoV.

What Are The Symptoms
Most people with MERS-CoV develop respiratory
illness with these symptoms:
Fever above 100.4F
Cough/ Runny nose
Shortness of breath
Pneumonia
Chills/ Body Aches
Sore Throat
Headache
Nausea/Vomiting
Diarrhea
Symptoms usually develop 2-14 days after exposure
to a person infected with MERS-CoV
Or following travel from countries in or near the
Arabian Peninsula within 14 days before onset of
symptoms.

Travelers Health Risks
Of 100,000 travelers to a developing country for 1 month:

50,000 will develop some health problem
8,000 will see a physician
5,000 will be confined to bed
1,100 will be incapacitated in their work
300 will be admitted to hospital
50 will be air evacuated
1 will die
Steffen R et al. J Infect Dis 1987; 156:84-91

The Patient: Medical Issues
Age-specific issues
Underlying illness, immunosuppression
Systems review
Medical history
Medication use
Vaccination history
Allergies
Contraindications to vaccines and medications
206
The Patient: Other Issues
Reproductive
Pregnant
Breastfeeding
Preconception
Risk-taking behaviors

Travel Itinerary
Full itinerary
Dates, duration, stopovers
Seasonal considerations
Styles of travel
Rural vs. urban
Budget vs. luxury
Accommodation
Hotel vs. camping
Activities
Business vs. tourism
Adventure, safari
Missionary/Humanitarian/NGO

Travel Health Resources
CDC Travelers Health Website
www.cdc.gov/travel
World Health Organization
www.who.int/int
State Department
travel.state.gov
International Society of Travel Medicine
www.istm.org
Health Information for International Travel
CDC Yellow Book
International Travel and Health
WHO Green Book

Deaths Related to International Travel
N = 2463
Hargarten S et al, Ann Emerg Med, 1991. 20:622-626

Infectious Disease Risks to the
Traveler
Malaria Schistosomiasis
Diarrhea Tuberculosis
Leishmaniasis Leptospirosis
Rabies Polio
Dengue Yellow Fever
Meningococcal Measles
Meningitis JEV
ETC. 211
Other Risks to the Traveler
Accidental injury
Environmental hazards
Crime and assault
Psychiatric problems
Animal bites, stings and envenomations
Dermatologic disorders
Altitude
.

Immunizations to Consider for Adult Travelers
Routine Travel related

Diphtheria* Hepatitis A
Tetanus* Hepatitis B
Pertussis* Typhoid
Measles + Rabies
Mumps+ Meningococcal disease
Rubella + Polio
Varicella Japanese encephalitis
Pneumococcus Yellow Fever
Influenza

Travel Medications:
Prophylaxis & Self Treatment
Malaria
chloroquine, atovaquone/proguanil (Malarone),
doxycycline, mefloquine (Lariam), primaquine
Diarrhea
quinolone, azithromycin
Altitude
acetazolamide
Motion sickness
scopolamine, dimenhydrinate (Dramamine)

Patient Counseling
Sufficient time for patient education

Tailored to suit traveler
Fitness for travel
Understanding impact on existing conditions
Advisability of destinations

Travel Preparation
Travel health insurance

Medical care
Hospitalization
Evacuation
Obtaining medical care abroad
Awareness of travel notices
Hand washing and hygiene

Environmental Precautions
Air Travel
Jet Lag
Sun Protection
Extreme Heat and Cold
dehydration, heat stroke
hypothermia, frostbite
Altitude
Water recreation
Drowning, boating & diving accidents
Risk of schistosomiasis or leptospirosis
Biological and chemical contamination

Food and Water Precautions
Bottled water
Selection of foods
well-cooked and hot
Avoidance of
salads, raw vegetables
unpasteurized dairy products
street vendors
ice

Vector Precautions
Covering exposed skin

Insect repellent containing DEET 25 50%
Treatment of outer clothing with permethrin
Use of permethrin-impregnated bed net
Use of insect screens over open windows
Air conditioned rooms
Use of aerosol insecticide indoors
Use of pyrethroid coils outdoors
Inspection for ticks

Bloodborne and STD Precautions
Prevalence of
STDs
Hepatitis B
Hepatitis C
HIV
Unprotected sexual activity
Commercial sex workers
Tattooing and body piercing
Auto accidents
Blood products
Dental and surgical procedures

Animal Precautions
Animal avoidance
Rabies
Specific animal threats
Medical evaluation of bites/scratches
Post exposure immunization and immunoglobulin
Envenomations
Snakes, scorpions, spiders
Maritime animals

Injury and Crime
Vehicles
Risk of road and pedestrian accidents
Night travel
Seat belts and car seats
Use of drugs and alcohol
Understanding local crime risks

Scam awareness
Situational awareness
Location avoidance

Travel Emergency Kit
Copy of medical records and extra pair of glasses
Prescription medications
Over-the counter medicines and supplies
Analgesics
Decongestant, cold medicine, cough suppressant
Antibiotic/antifungal/hydrocortisone creams
Pepto-Bismol tablets, antacid
Band-Aids, gauze bandages, tape, Ace wraps
Insect repellant, sunscreen, lip balm
Tweezers, scissors, thermometer

Post-Travel Care
Post-travel checkup
Long term travelers
Adventure travelers
Expatriates in developing world
Post-travel care
Fever, chills, sweats
Persistent diarrhea
Weight loss

Thank You

Dr. Jarir Tadulako - June 2016

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WELCOME

Jarir At Thobari, MD, MSc, DPharm, PhD

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Infectious diseases that either occur

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

10 mm induration Considered positive in:

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

GROUP DRUGS COMMON TOXICITIES COMMENTS

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

GROUP DRUGS COMMON TOXICITIES COMMENTS

Injectable agents Aminoglycosides: Irreversible ototoxicity (6-18%) Parenteral administration

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Neurologic disturbance Use of ciprofloxacin is not

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Study Outcomes at 120 Weeks According

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Q : Do I capture Q : Is my model Q : What are the main

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

GLOBAL ASIA WHO SEARO

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

DIARRHEA DEATH due to LOST (& LACK) of:

WATER & ELECTROLYTE

Height Fitness I.Q.

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Risk of Particular Event Event

1 : 205 611,000 deaths

1 : 50 2.4 million inpatient visits

1:1 114 million

Rotavirus is said to be a democratic virus infecting all

3 Glass RI et al. Acta Pediatr Suppl 1999; 88 (426): 2-8.

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Affects young children more: 72% 6-23 months Hospitalizations

RV+ diarrhoea: higher rates dehydration,

Rotavirus Burden Indonesia Per Year

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Department of Pharmacology & Pharmacotherapy, Fac. Medicine UGM

Sardjito Hospital, Yogyakarta 170 51 (30.0)