Firhat Esfandiari, RS.

Pertamina Bintang Amin Hospital

OUTLINE OF PRESENTATION
• FACTORS CONSTRIBUTING TO
EMERGENCE OF INFECTIOUS
DISEASES;
• STATUS OF INFECTIOUS DISEASES IN
SEA REGION (Emerging, Re-emerging,
New Diseases);
• STATUS OF INFECTIOUS DISEASES IN
INDONESIA (Emerging, Re-emerging,
New Diseases).
MAP OF SEA REGION AND
INDONESIA
FACTORS CONSTRIBUTING TO EMERGENCE
OF INFECTIOUS DISEASES

Catagories Specific examples

Societal events Economical improvement; war or civil con-

conflict, population growth and migration;
Health care New medical devices; drug causing of immu
nosuppression, widespread use of antibiotics
Food production Globalization of food supplies; changes in
food processing, packaging, & preparation
Human behavior Sexual behavior; drug use; travel; diet; out
door recreation; use of day care facilities
FACTORS CONSTRIBUTING TO EMERGENCE
OF INFECTIOUS DISEASES

Catagories Specific examples

Environmental changes Deforestation; changes in water ecosystems;

flood/drought; famine; global warning;
Public health Infra- Reduction of prevention program; inadequate
structure communicable disease surveillance; laborato
ry scientist; lack of trained personel (eg. Epi-
demiologist, lab.scientist, etc.
Microbial adaptation Change in virulence and toxin production;
and change development of drug resistance; microbes as
cofactors in chronic diseases.
 FACTORS INFLUENCED TO INCREASED OF
INFECTIOUS DISEASES IN INDONESIA

(1) Economic Development, Changed of Demografic and Life

Style in Community;
(2) Development of Transportation  Increased of Traveller
inter-region, island, and city in Indonesia.
(3) Environmental changed  Disaster in many areas in
Indonesia, and many projects irigations ?
(4) Limitation of manpower and health sevices in community;
(5) Non hygiene of foodhandling  transmission of bacteriae
(Salmonella typhi);
(6) Mutation and Evolution of organism  new strain emerge
and antibiotics resistancy.
 STATUS OF INFECTIOUS DISEASE IN
SEA REGION
EMERGING DISEASES :
1. TUBERCULOSIS; 7. HEPATITIS C
2. MALARIA 8. HEPATITIS E
3. DENGUE/DHF; 9. CHIKUNGUNYA
4. JAPANESE ENCEPHALITIS; 10. HIV / AIDS
5. MENINGITIS 11. CHOLERA O139
6. HEPATITIS B 12. NIPAH VIRUS.
 STATUS OF INFECTIOUS DISEASE IN
SEA REGION ; EMERGING DISEASES

1. TUBERCULOSIS :
Number one killer infection. In 1995,
there was approximated 3,5 million
new cases of tuberculosis
complicated with HIV/AIDS, the new
dimension of tuberculosis
epidemiology.
 Tuberculosis
A Global Emergency

• TB kills 5,000 people a day & 2 million / year;

• One third of the world’s population is infected;
• More than 100,000 children will die needlessly
from TB / year;
• Hundreds of thousands of children will become
TB orphans / year’;
• HIV and MDRTB will make the TB epidemic
much more severe unless urgent action is
taken;
TB is a Leading Killer of Women

Deaths among 605.000

women 538.000
493.000

101.000
48.000

Tropical STD Maternal Malaria TB

Diseases Mortality
TB is the leading single infectious cause of
death in South-East Asia
800
Number of deaths (1000s)
700

600
Deaths from infectious
agents in South-East
500
Asia
400
300

200

100

0
Tuberculosis HIV Measle STD Malari Tropical
s a Diseases
 STATUS OF INFECTIOUS DISEASE IN
SEA REGION : EMERGING DISEASES

2. MALARIA :
Approximated 1.2 billion people live of in
endemic malaria countries. 23.6 million
new cases and 40.000 of death, drug
resistance and insecticide resistance.;

3. DENGUE/DHF :
the most causal factor of hospitalization
for children/young adult in many
countries. Approximated millions cases
and thousands mortalities per years.
 STATUS OF INFECTIOUS DISEASE IN
SEA REGION : EMERGING DISEASES
(4) JAPANESE ENCEPHALITIS : The main problem is in
India, Nepal, Ceylon and Thailand. Approximated 20.000
cases and 4000 mortalities per years. Immunization gives
the hope of live in India, Ceylon and Thailand.
(5) MENINGOCOCCAL MENINGITIS : Reported attack
many countries, with approximately 21.000 cases and
5000 mortalities per years

(6) HEPATITIS B : The causal factor of liver cancer and liver-

cirrhosis. Approximated more than 80 million carries. EPI
on women can decrease the morbidity in Thailand and
Indonesia.
 STATUS OF INFECTIOUS DISEASE IN
SEA REGION : EMERGING DISEASES

(7) HEPATITIS C : The secreening result of HVC

in general population found the associa-
tion of HVC virus with the primary liver Ca
in India, Indonesia, Myanmar & Thailand.
(8) HEPATITIS E : In many countries of SEA
region causes many explosion by
waterborne disease; high rate mortality
particularly in pregnant woman.
 STATUS OF INFECTIOUS DISEASE IN
SEA REGION : EMERGING DISEASES

(9) Chikungunya :

After causing outbreaks in India, Sri Langka,

Burma and Thailand. The virus spread into
Philippines, Indonesia for the first time from
1982 to 1985. About 80% of patients had some
form of joint symptoms, either arthragia or
arthritis, involving the small joint of hand and
feet.
 STATUS OF INFECTIOUS DISEASE IN
SEA REGION : EMERGING DISEASES
(10) Nipah Virus
A major outbreak of disease in pig and human in
the Malay Penninsula Sept. 1988 to April 1999
resulted in 265 infected persons, 105 of whom
died and destruction of about 1.1 million pigs.
The predominant clinical syndrome in human
was encephalitic, with fever, headache, myalgia,
drowsiness & disorientation, sometimes
proceeding to coma within 48 hours.
 STATUS OF INFECTIOUS DISEASE IN
SEA REGION : EMERGING DISEASES

(11) HIV/AIDS : Two countries in the region,

Cambodia and Papua New Guinea, are a
particular concern because the high and
increasing incidence of HIV infection,
primarily through heterosexual transmission.
(12) CHOLERA O 139 : The first outbreak in
Southern India and Bangladesh in 1992; and
then in 1996 in Myanmar, Nepal Srilangka,
and the fact mutation strain from Cholera eltor
to  Cholera O 139.
 STATUS OF INFECTIOUS DISEASE IN
SEA REGION : RE-EMERGING DISEASE

(1) PLAQUE (PEST) : Suddenly EMERGED in India

(1994) after 27 years looses. We must MORE
attention in India, Indonesia, Myanmar
and Nepal.

(2) KALA-AZAR : It hardly ever seen since 1960.

In 1995, it become the serious problem in
India, Bangladesh and Nepal with 100.000
cases and 5000 mortalities.
EMERGING INFECTIOUS DISEASES IN
INDONESIA
(A) Vector borne Disease : (1) DF/DHF (2)
Chikungunya (3) Japanese
Encephalitis (4) Malaria (5) Filariasis
(6) Leptospirosis (7) Toxoplasmosis;
(B) Sexual Transmitted Disease (STD);
(C) Airborne Disease : (1) Tuberculosis (2)
Influenza.
(D) Food and Water borne Disease : (1)
Typhoid Fever (2) Diarrhoae.
 EMERGING INFECTIOUS DISEASE IN
INDONESIA : VECTOR BORNE DISESASE

(1) DENGUE and DHF : Since 1968, it tend to

increase particularly in urban AND SEMI-
URBAN for childhood and YOUNG ADULT.

(2) CHIKUNGUNYA : It is endemic in Indonesia,

the vector is the same with DhF. it Doesn’t
cause mortality but loose OF the working
hours.
 Incidence Rate (IR) and Case Fatality
Rate (CFR) of DF/DHF by Year in
80 Indonesia, 1968-2007
71.18
IR (per 100,000 pop)
60 CFR(%)
IR and CFR

40

20

1.01
0
1968
1970
1972

1974
1976
1978

1980
1982

1984

1986
1988

1990
1992
1994

1996
1998

2000
2002
2004

2006
2008
Year
 No.of DF/DHF Infected Areas
in Indonesia, 2007

Province District

35 33 33 600

30
500 480

25
400 357
20
300
15
200
10

100
5

0 0
No. of No. of No. of No. of
province infected district infected
Map of DF/DHF Incidence by
Province in Indonesia, 2007

<5 5-19 20-50 >50

IR=incidence rate (per 100,000 population)

 Yearly Average DF/DHF Case by Islands
in Indonesia for 3 Years, 2005-2007

Non Java-Bali (22.4%)

(26 provs)
Java-Bali (7 provs) (77.6%)

Yogyakarta (1.5%)

Banten (2.7%)

Bali (4.2%)

Central Java (10.3%)

East Java (16.5%)

West Java (20.4%)

Jakarta (21.9%) (100.0%)

Indonesia

0 20000 40000 60000 80000 100000 120000 140000

 No.of DF/DHF Case by Month
in Indonesia, 2005-2007

30000

25000
2007
No. of DF/DHF case

20000
2006

15000

average
10000
2005
5000

0
Jan Feb Mrch Apr May Jun Jul Agt Sep Oct Nov Dec
EMERGING INFECTIOUS DISEASES IN
INDONESIA : VECTOR BORNE DISEASE

(3) JAPANESE ENCEPHALITIS :

It was endemic in Bali, North

Sumatra, North Celebes, Papua and
pig CATTLE RAISING area; Culex
tritaenorrt-hynchus, C. gellidus,
C.fatigans is the most vector found
in Indonesia
 Japanese Encephalitis (JE)
• Most important global cause of arboviral
encephalitis with > 50,000 cases and 15,000 deaths
reported each year.

• Only about 1 in 250 JE infections result in

symptomatic illness.

• Primarily affects children 1 to 15 years of age.

• Incubation period is 5 to 14 days.

• If unrecognized, mortality is up to 30% with half

of survivors sustain severe neurological
sequelae.
Who is at risk for encephalitis?

Anyone can get encephalitis. However,

the following groups are at higher risk:

• Young children or the elderly.

• Persons with HIV.
• Persons taking immuno-suppressive drugs.
• Persons living in encephalitis endemic
areas.
Clinical manifestations of encephalitis

• The clinical presentation of encephalitis is

generally nonspecific:
— Fever, headache, vomiting, occasionally accompanied
by seizures, mental status changes, and/or focal
neurologic deficits

• Any patient presenting with fever and an

abnormal neurologic exam should be
evaluated closely for encephalitis!
 Common symptoms of encephalitis
Lethargy
Sudden fever

Headache Change in
consciousness

Irritability or
restlessness

Tremors or
Vomiting and
convulsions
diarrhea
Important points to remember

• Acute encephalitis is a medical emergency.

• Any patient presenting with fever and
impaired mental status or neurological exam
should be evaluated for encephalitis.
• The diagnosis of encephalitis is clinical.
— Don’t forget the value of a good history and
physical exam.

• All suspected cases of encephalitis should be

reported to local authorities.
EMERGING INFECTIOUS DISEASES IN
INDONESIA : VECTOR BORNE DISEASE

(4) MALARIA :

The malaria control in Indonesia

DiDn’t optimally result. It caused by
monetary crisis, environmental
changes, plasmodium drug
resistance, vector insecticide
resistance, migration, etc.
EMERGING INFECTIOUS DISEASES IN
INDONESIA : VECTOR BORNE DISEASE

(5) FILARIASIS :
TRANSMITTED by many vectors :
Culex fatigans, Mansoni, AnopHeles
and Aedes MOSQOITOES.
Until August 2007 in Indonesia, it
was found 11.189 cases of clinical
chronic filariasis spread on 378
municipals with prevalence rate
average (Mf rate0 = 19,78)
EMERGING INFECTIOUS DISEASES IN
INDONESIA : VECTOR BORNE DISEASE

(6) LEPTOSPIROSIS :

caused by Leptospira bacteriae,

transmitted by THE
CONTAMINATED urine of the
rats. Found in 14 provinces in
Indonesia.
EMERGING INFECTIOUS DISEASES IN
INDONESIA : VECTOR BORNE DISEASE

(7) TOXOPLASMOSIS : Caused by

Toxoplasma gondii; Clinical manifestation
of toxoplasmosis were not specific;
spread out among many countries in the
world including Indonesia. The
prevalence of toxoplasmosis among
Indonesian people was 26,3% i pregnant
women, 51.48% in abortion women, 24.2-
32% in infertile women.
 EMERGING INFECTIOUS DISEASES IN
INDONESIA : VECTOR BORNE DISEASE

SEXUALLY TRANSMITTED DISEASES (STD) :

• WHO was approximated 340 million new cases
of STD per year in the world (Gonorhoea,
Clamydia infection, Syphilis, Trichomoniasis and
HIV/AIDS).

• Prevalence data in Indonesia wasn’t adequate,

caused by weakness of reporting and recording
system.
EMERGING INFECTIOUS DISEASES IN
INDONESIA: AIR BORNE DISEASE

(1) INFLUENZA : the mutation of influenzae

virus to cause difficulty of the preventive
efforts in community.
(2) TUBERCULOSIS : The emergence of
this disease caused by the medical usage
wasn’t adequate, low awareness and the
increase of HIV/AIDS incidence, etc.
 EMERGING INFECTIOUS DISEASES IN
INDONESIA

(D) FOOD AND WATER BORNE DISEASES.

(1) TYPHOID DAN SALMONELLOSIS : The
sanitary factor and hygienic food take was
responsibility on the increase of the morbidity of
typhoid fever.
(2) DIARRHOEA : The strain of Cholera Vibrio O
139 from Bangladesh was a potentially factor to
increase the case of diarrhoea in Indonesia.
RE-EMERGING DISEASES IN
INDONESIA
(1) RABIES
(2) PLAQUE (PEST)
(3) ANTRAX
(4) TAENIASIS/CYSTICERCOSIS
(5) SCHISTOSOMIASIS
(6) FASCIOLOPSIS BUSKI
RE-EMERGING INFECTIOUS DISEASES
IN INDONESIA

(1) RABIES : Still found in 18 provinces in

Indonesia such as West Java, Jakarta,
Aceh, North Sumatra, West Sumatra, Riau,
etc.
“If your patient with rabies survive, it
absolutely means the diagnosis was
wrong”
 RABIES : EPIDEMIOLOGY
Incidence worldwide  35,000 deaths
Asia
(35,000 deaths)
1
India Africa Americas
Pakistan (206) (153) Europe
(33)
Bangladesh
Vietnam
2 3
Philippines Algeria Brazil 4
China Morocco Mexico Kazakhstan
Sri Lanka South Africa Peru Georgia
Indonesia ? Ethiopia Ecuador Russian Fed.

Adapted from the WHO World survey of Rabies n°31 WHO/EMC/ZOO/97.1

 RABIES CLINICAL PICTURE

 Prodromal Symptoms
• Lasts from 2 to 10 days
• Non - specific ( malaise, fatigue, headache , fever, pain or
parasthesia close to the site of exposure)

 Disease itself
• Objective signs of nervous system involvement

Encephalitic TWO Paralytic

(Furious) rabies, CLINICAL (Dumb) rabies,
80% of cases FORMS 20% of cases
 Rabies: clinical forms *

ENCEPHALITIS TYPE (80%) PARALYTIC

TYPE (20%)
Hallucinations, bizarre behaviour,

Upto 30 days
Complete paralysis
hydrophobia / aerophobia
Coma
Paralysis

Death (respiratory failure)

2 - 7 days

Coma

Death (respiratory failure)

RE-EMERGING INFECTIOUS DISEASES
IN INDONESIA

(2) PLAQUE (PES) : Since 1978, 3 provinces

in Indonesia (East Java, Central Java and
Yogyakarta) notified as the focus of this
diseases.
(3) ANTHRAX : the last 5 years, anthrax re-
emerged in 4 provinces (East Nusa-
tenggara, Central Java, West Java and
West Nusatenggara)
RE-EMERGING INFECTIOUS DISEASES
IN INDONESIA

(4)TAENIASIS/CYSTICERCOSIS : Reported
as serious problem in Papua. In 1995 found
3.632 cases (+) 14 mortals.

(5)SCHISTOSOMIASIS : Endemic in Nabu

Valley and Lindu Lake South East Celebes.

(6)FASCIOLOPSIS BUSKI : In South and

Central Borneo
NEW INFECTIOUS DISEASES IN
INDONESIA

(1) HIV/AIDS
(2) SARS (SEVERE ACUTE RESPIRATORY
SYNDROME)
(3) AVIAN FLUE
(4) MENINGITIS MENINGOCOCCUS
(5) HAND FOOD & MOUTH DISEASE
(HFMD)
(6) HANTA VIRUS INFECTION
NEW INFECTIOUS DISEASE IN
INDONESIA

(1)HIV/AIDS : number of
hiv/aids cases was
increased every year; the
user of needle for drugs
in Jakarta and other
metropolitant city get
increased.
NEW INFECTIOUS DISEASE IN
INDONESIA

(2) SARS :
SEVERE ACUTE
RESPIRATORY SYNDROME
 THE SUSPECT ON SARS
Warning of this conditions :
1. High fever > 100,5 F or > 38 C

2. Found one or more the symptom of dry cough, short

winded, difficult to take a breath, hypoxia, pneumonia
on thorax roentgen.

3. Unspecific : symptoms : headache, cramp, faint,

anorexia, reddish, diarrhea, confuse.

4. Interaction with corona virus infected person at least 10

days before.

5. Visiting travel warning countries : Hong Kong, China….

 NEW INFECTIOUS DISEASE IN
INDONESIA

(3) AVIAN INFLUENZA :

Spread in Indonesia in 2003 :
 The Department of Agriculture
notified in January 2004
 that the subtype of AI was H5NI
What is happening now…

 H5N1 in birds in 60 countries in Africa,

East Asia and the Pacific, South Asia, the
Near East and Europe and Eurasia.

 45 of those countries reported their first

H5N1 infection in birds since 1Feb 06.
 Geographic Distribution of human AI by Province
in Indonesia (June 05 – Febr 08)

North
Sumatra
C= cases (129)
C8 D7 D= death (105)
CFR = 81,4%
South
Sumatra
C1 D1

Riau C6
D5

West
Sumatra
C3 D1 DKI Jakarta
C32 D27 South
Sulawesi
C1D1
Lampung
C3 D0

Bali
Banten Central C2 D2
WestJava East Java
C26 D22 Java
C31 D25 C7 D5
C11 D9
NEW INFECTIOUS DISEASE IN
INDONESIA

(4) MENINGITIS MENINGOCOCCUS :

Causes by Neisiria meningitides,
potentially increase by
pilgrimages to Mecca and
Indonesia workers in the Gulf
Countries.
NEW INFECTIOUS DISEASE IN
INDONESIA
(5) HAND, FOOT & MOUTH DISEASE (HFMD) 
EV-71, In East and South China, in Mai
2008 found 24932 cases and killed 34
children under 1 year old.
The symptom is like flu syndrome,
headache, throat inflammation. It was
also signed by the reddish on the palm of
hand, sole of food, and mouth with vesicle
 could be walk to brain vessel and
membrane.
 NEW INFECTIOUS DISEASE IN
INDONESIA

(6)HANTA VIRUS INFECTION :

Many countries in South East Asia
are unaware of the importance of
Hantavirus Infections
and give them low priority
 Hantavirus (HV) Infections
• In South East Asia, evidence of HV in
human has been reported from Korea,
Philippines, Singapore, and Thailand
• In Indonesia, a serological study
indicated the presence of Seoul-like virus
in wild rats
• So far, no human cases have been
reported ? (’01, any cases in Semarang,
‘04 in Bandung)
 Hantavirus Serologically Reported Areas

Batam

Serang

Jakarta

Subang Makassar
Semarang
Maumere
 CLINICAL MANIFESTATION

 Hantavirus Pulmonary Syndrome:

Fever, myalgia, headache, Gastrointestinal
symptoms (nonspecific) cough, respi-
ratory insufficiency

 Hemorrhagic Fever with Renal

Syndrome
Nonspecific symptoms  extreme
albuminuria, impaired renal function
 CONCLUSION
• Many factors constribute to infectious disease
emergence in the world : societal events, health
care, food production, human behavior,
environmental changes, public health
infrastucture, microbial adaptation and change
etc.
 CONCLUSION
• In South Asia Region : the emerging infectious
diseases were TBC, malaria, DHF, JE, meningitis,
hepatitis, chikungunya, HIV/AIDS, Cholera O 139,
Nipah Virus Infection.
 CONCLUSION (cont’)
• New Diseases in Indonesia were HIV/AIDS,
SARS, Avian Influenzae, Meningitis, HFMD,
Hanta virus infection.
• Emerging Infectious Diseases in Lampung were
DF/DHF, Chikungunya, Malaria, STD, TBC.,
Typhoid fever, Diarrhoae.