BAB I

PRELIMINARY

1.1. Background

The Community Medical and Community Health Block is the twenty-second block
in the 7th semester of the Competency Based Curriculum (KBK) at the Faculty of
Medicine, Muhammadiyah University of Palembang, which demands the mastery of the
material, both knowledge and skills that will support to become a superior doctor,
qualified, and islamic.
On this occasion, C case scenario scenario C which presented cases related to
Outbreak and Occupational Health.

1.2. Purpose and Objective

The purpose and objectives of the Case scenario tutorial C, namely:

1. As a report task group tutorial that is part of the learning system Competency Based
Curriculum (CBC) at the Faculty of Medicine, Muhammadiyah University of
Palembang
2. Can solve the case given in the scenario with the method of analysis and learning
group discussion.
3. Achieving the objectives of the tutorial learning method.
 BAB II
DISCUSSION

2.1 Data Tutorial

Tutor : dr. Iskandar
Moderator : Meitria Nur Sabrina
Desk Secretary : Soleha
Notulis : Indah Ulfanov Pratiwi
Time : Session 1: Tuesday, 07 November 2017
Time: 13.00-15.30 WIB
Session 2: Thursday, 09 November 2017
Time: 13.00-15.30 WIB

Rule of tutorial :
1. Switch the phone off or in silence.
2. Raise your hand when going to argument.
3. Permission when going out of the room.
4. Prohibited activate the mobile phone when prosestutorial take
place.
5. Prohibited from bringing food and drink during the tutorial
process.

2.2 Tutorial Scenario

Dr. Beny just worked for 6 months at the Puskesmas beringin Jaya. He got a
report from his surveillance staff that this month there was an increase in cases of
diarrhea, acute respiratory infections ( ARI) significantly. Beringin Jaya has been a
village with endemic diarrhea and ARI.
Puskesmas located is in Beringin Jaya village with population of 20.000. Beringin
Jaya village is located on the river bank where the river is used by residents for
bathing, washing and defecating. At the base of the river there is a rubber processing
plant, where factory waste is directly flowed inti the river without prior treatment.
 The work of general population is as a forest encroachment farmer, where to open
their land to burn forest. Some of the population work as labor in rubber processing
plant, generally they work not using personal protective equipment.
Dr. Beny plan to investigate outbreaks to prevent transmission and to the seek the
source of disease transmission. He will also provide education to prevent transmission
of the disease.

2.3 Clarification of Problems

1. Surveillance staff : The monitoring of behavior activities or other changing
information for purpose of influenzing, managing, directing or protecting people.
2. Endemic : There is or usually a prevalence in the population at any
time.
3. Diarrhea : The discharge of water stools is often abnormal.
4. Personal protective equipment : Protective equipment that must be used when
working in accordance with the hazards of work to maintain the safety of the
workers themselves and those around them.
5. Acute respiratory Infection : Classified as upper respiratory tract infection or
lower respiratory infection.
6. Disease transmission : Means by which contagious, pathogenic
microorganism are spread from one person to other.
7. Rubber processing plant : Place of processing of raw rubber or natural
rubber which has undergone various technical development.
8. Provide public education : Educating the public on environmental,
physical, social, emotional, intellectual, and spiritual health.
9. Prevent transmission : Precautions for the spread of a disease.
10. Population : The whole number of people or residents in an area.
11. To investigate : Search out and examine the particular of in an attempt
to learn the facts of about something hidden.
12. Outbreaks : A sudden increase in occurances of a disease in
particular time and place.
2.4 Identification of problems

1. dr. Beny just worked for 6 months at the Puskesmas beringin Jaya. He got a report
from his surveillance staff that this month there was an increase in cases of diarrhea,
acute respiratory infections ( ARI) significantly. Beringin Jaya has been a village with
endemic diarrhea and ARI.
2. Puskesmas located is in Beringin Jaya village with population of 20.000. Beringin
Jaya village is located on the river bank where the river is used by residents for
bathing, washing and defecati. At the base of the river there is a rubber processing
plant, where factory waste is directly flowed inti the river without prior treatment.
3. The work of general population is as a forest encroachment farmer, where to open
their land to burn forest. Some of the population work as labor in rubber processing
plant, generally they work not using personal protective equipment.
4. Dr. Beny plan to investigate outbreaks to prevent transmission and to the seek the
source of disease transmission. He will also provide education to prevent transmission
of the disease.

2.5 Problem analysis

1 a. What are the tasks of the surveillance staff?

Jawab:
Based on the Decree of the Minister of Health No. 1479 / Menkes / SK / X / 2003 on
Guidelines on the Implementation of Epidemiology Surveillance System for Infectious
Diseases and Non Communicable Diseases, the role of surveillance of puskesmas is:
1. Data Collection and Processing
The Puskesmas surveillance unit collects and processes STP Puskesmas data from the
outpatient registers & inpatient registers at Puskesmas and Puskesmas Pembantu,
excluding data from non-Puskesmas service units and health cadres. The collection and
processing of data is utilized for analysis materials and recommendations for follow-up as
well as data distribution.

2. Follow-up Analysis and Recommendation

The Puskesmas surveillance unit conducts monthly analysis of potential outbreak
diseases in its area in the form of a table according to the village / kelurahan and the
weekly disease trend graph, then informs the results to the Puskesmas Head, as the
implementation of local area monitoring (PWS) or early awareness system of potential
outbreak diseases at the Puskesmas. If there is a tendency to increase the number of
potential disease outbreaks, the Head of Puskesmas will conduct an epidemiological
investigation and inform the District Health Office. The Puskesmas surveillance unit
conducts an annual analysis of disease progression and links it to risk factors,
environmental changes, and program planning and success. Puskesmas utilize the results
as an annual profile material, Puskesmas planning materials, program and sector related
information and District / Municipal Health Office.

3. Feedback
Puskesmas surveillance unit sent monthly report attendance and data recovery request to
Puskesmas Pembantu in its working area.

4. Reports
Every week, Puskesmas send PWS data of potential disease of KLB PWS KLB (attached
form 3). Every month, Puskesmas sends STP Puskesmas data to District / City Health
Office with the type of disease and its variables as form STP. EFA (attached form 4). In
the PWS data of potential outbreaks and STP data, this Puskesmas does not include data
on non-health service units and health cadres data Each week, non-Puskesmas Service
Units send PWS data of potential outbreaks to District Health Offices.
(KMK RI, 2003)

b. What is the meaning of dr.Beny receiving a report from sruveilans staff that this
month there is an increase in cases of significant and endemic diarrhea and respiratory
infection in Beringin Jaya village?
c. What is the meaning surveillance staff?
Jawab:
 Based on the Decree of the Minister of Helath no. 45 / Menkes / 2014 on Guidelines on
the Implementation of health surveillance. Health Surveillance is a systematic and
observational activity continuous data and information about the incidence of the disease
or health problems and conditions that affect the occurrence improvement and
transmission of disease or health problems to obtain and provide information to guide
action control and countermeasures effectively and efficiently.

d. How are surveillance measures?

Jawab:
The decree of the minister of health of the republic of indonesia number 1116 / menkes
/ sk / viii / 2003 concerning guidelines for implementing epidemiology surveillance
system.
Health epidemiological surveillance activities are activities that are carried out
continuously and systematically with the working mechanism as follows:
1. Identification of cases and health problems as well as other relevant information
2. Recording, reporting, and data processing
3. Analysis and interpretation of data
4. Epidemiological studies
5. Dissemination of information to units that need it
6. Make recommendations and follow-up alternatives
7. Feedback

e. Anyone who becomes surveillance?

Answer:
Human resources of health epidemiology surveillance system include:

1. Epidemiologists (S1, S2, S3)

2. Epidemiological surveillance officers trained field epidemiologic assistants,
and trained puskesmas officers epidemiologic surveillance
3. Health unit managers who have an epidemiological orientation
4. Position of epidemiological function
5. Entomology functional position
6. Functional position of sanitarian
7. Functional position statistisi
 8. Laboratory human resources
9. Other related human resources

f. What an indicator of an area is said to be endemic?

Answer:
g. Anything related to endemic and for example?
Answer:
1. Endemic: persistent disease in a particular place, population and community
(minimum 3 years in a row). For example: DHF
2. Epidemic (epidemic): an increase of disease beyond normal (2 x fold before) in the
community. Example: filariasis
3. Pandemic: epidemics that exist in a very large area (worldwide)
Example: H1N1 2009 (Swine flu)
4. Sporadic: the ongoing incident is in short time and at the time of each observation
the events are not interconnected in the manufacturing process. For example: NE
disease.

h. How does disease travel naturally and transmisinya? (diarrhea and ARI)
Answer:
Diarrhea:
Transmission of infectious germs that cause diarrhea is transmitted through
Face-Oral germs can be transmitted when entered into the mouth through food, drink
or contaminated objects with feces, such as fingers, food containers or drinking
places to be washed with contaminated water. People who are covered by clean water
supply have a lower risk of diarrhea than people who do not get clean water.
Communities can reduce the risk of diarrhea by using clean water and protecting the
water from contamination from the source to storage at home (Soepardi, 2011).

2 a. What is the relationship of Beringin Jaya village located on the river bank with the
condition of river use for bathing, washing and defecation purposes?
Answer:
 Rubber factory by the
river

Pollution of the river water

The village of Beringin
Jaya (located on the edge of
the river)

Community behavior habits use

river water for bathing, washing,
defecation
(water washed diseases)

Endemis diarrhea
Diarrhea

There is no influence
from outside the village

b. What is the impact on the health of residents who use river water for bathing,
washing and defecation?
Answer:
According to (Workie, Amare, Melake Demena et al. 2003) which
includes wateborne disease are:
Categories of Diseases Causes Caused Transmission
agents organisms route of disease

Bacterial Shigellosis Shigella. Sp Man-Feces-water-

food and drink-
human

Thyphoid Salmonella thypi Man-Feces-water-

dan salmonella food and drink-
parathypi human
Cholera Vibrio Cholera Man-Feces-water-
food and drink-
human
Acute E. coli Man-feces-water-
Gastroenteritis human
Viral Infectious hepatitis Hepatitis A virus Man-feces-water-
Hepatitis E Virus food and drink-
human

Poliomyelitis Polio virus Man-feces-water-

human
Acute Gastroentritis Rota Virus Man-feces-water-
human

Protozoal Amebiasis Entamoeba Man-feces-water-

Hystolitica food and drink-
human

Giardiasis Giardia lamblia Man-feces-water-

food and drink-
human
Helminths Dracunculiasis Drancunculus Man-water-human
(Guinea Worm) medinesis

c. What are the types of diseases associated with water as transmissions?

Answer:
According to the way of spreading, there are four kinds of diseases that
contagion involves water:
1) Water Borne Disease
That is a disease transmitted directly through drinking water, where the drinking
water contains pathogenic germs causing the concerned to become sick. Included in
this category are cholera, typhoid, dysentery etc.
2) Water Washed Disease
It is a disease caused by poor water hygiene. Mode of transmission may be: a) GI
infection, such as diarrhea in children, b) Infection of the skin and eyes, such as
scabies and trachoma. c) Diseases through rodent urinary fluid, such as leptospirosis.
3) Water Based Disease
Is a disease caused by seeds of disease that most of the life cycle associated with
water. An example of this disease is Schistosomiasis.
4) Water Related Vectors
It is a disease caused by a disease vector that partially or all of its longings is in the
water. Included in this category are dengue fever, malaria, filariasis, etc.
(Priyanto, 2011)

d. What the chain of transmission disease?

Answer:

f. What are the types of latrines?

Answer:
 g. How to waste factory treatment?
Answer:
Wastewater treatment methods:
Wastewater treatment is intended to protect the environment against waste water
pollution.Some simple ways of waste water treatment include:
a) Dilution
The wastewater is diluted until it reaches a sufficiently low concentration, then is
discharged into water bodies.
b) Oxidation ponds (oxidation ponds)
In principle, this way of processing is the utilization of sunlight, algae, batteries
and oxygen in the process of natural cleansing. Wastewater is flowed into a large
rectangular pool with a depth of between 1-2 meters. The walls and bottom of the
pond need not be lined with anything. The location of the pond should be far from
residential areas, and in open areas, thus allowing good wind circulation.
c) Irrigation
Wastewater is poured into open trenches dug, and water will seep into the
ground through the base of the trench walls.
(Notoatmodjo, 2011)

h. What are the regulations on waste disposal?

Answer:
i. What is needed in waste disposal?
Answer:

j. How is the management of waste factory waste?

Answer:

3. a. What are the diseases caused by the smoke of forest fires?

Answer:
b. How to natural history of the smoke pollution disease?
Answer:
c. What good tools are used by rubber farmers and workers processing rubber processing?
Answer:
Forest encroachers:
1. Head protector (hat, head hood)
2. Eye and face protection devices (safety goggles, masks)
3. Earplugs (ear plugs, earplugs)
4. Respiratory protective equipment (mask)
5. Hand protective device (gloves)
6. Foot protector (boots)

Rubber Factory Workers:

1. Head protector (safety helmet)
2. Eye and face protection devices (safety goggles, masks)
3. Earplugs (ear plugs, earplugs)
4. Respiratory protective equipment (mask)
5. Hand protective device (gloves)
6. Foot protector (safety shoes).

d. What are the types of occupational diseases?

Answer:
According to the International Labor Organization (ILO), occupational accidents
are classified by 4 kinds:
1) Classification by accident type
a) Fall
b) Wrapped objects
c) Pounded or exposed to objects
d) Squashed by objects
e) Movements beyond ability
f) High temperature effect
g) Exposed to electric current
h) Contact of hazardous materials or radiation
2) Classification by cause
a) Machines, such as power generation machines, sawmills, and so on.
b) conveyance, land transport, air and water transport equipment.
c) Other equipment, such as burner and heating kitchens, refrigeration installations,
electrical appliances, and so on.
d) Materials, substances, and radiation, such as explosives, gases, chemicals, and so on.
e) Work environment (outside buildings, inside buildings, and below ground)
f) Other causes
3) Classification by nature of injury or abnormality
a) Fracture
b) Dislocation
c) Strain muscles
d) Bruises and other deep wounds
e) Amputation
f) Wounds on the surface
g) Concussion and crumbling
h) Burns
i) Sudden poisoning
j) Influence of radiation
k) And others
4) Classification according to location of abnormalities or injuries in the body
a) Head
b) Neck
c) Agency
d) Top member
e) Lower member
f) Plenty of places
g) Other location
(Notoadmojo, 2011)
 e. What is K3 and its system at the factory?
Answer:
K3 are all conditions and factors that can impact on occupational safety and
health for workers and others in the workplace.
OHSAS stands for Occupational Health and Safety Assessment Series
(OHSAS 18001) is an international standard for implementing Occupational Safety
and Health Management Systems in the workplace / company. Compulsory procedures
of OHS are contained in OHSAS 18001 in 2007 which are:
a. Hazard Identification, Risk Assessment and Control Procedures
b. Conformity Evaluation Procedure Against Legal Requirements, Regulations, And
Legislation on Occupational Safety and Health
c. Competency, Training and Awareness Procedures
d. Communication Procedures, Participation and Consultation
e. Document Control Procedures
f. Operational Control Procedures
g. Emergency Preparedness and Response Procedures
h. Performance Measurement and Monitoring Procedures
i. Procedures for Investigation and Incident Analysis
j. Non-Conformity, Corrective Action and Precautions
k. Record / Record Control
l. Internal Audit Procedures.

f. How is the OSH regulation in the factory?

Answer:
g. How to prevent occupational diseases?
Answer:
h. What is the relationship between occupational diseases and rubber workers?
Answer:

4. a. What is the meaning of dr. Beni want to investigate?

Answer:
b. What are the criteria of an area that is said to be an outbreak?
Answer:
An area may be specified in an outbreak, if it falls incorrectly one criterion as
follows:
a. The emergence of a particular infectious disease as referred to in Article 4 which was
previously absent or unknown in an area.
b. Increased incidence of continuous pain for 3 (three) periods in hours, days or weeks
consecutively according to the type of illness.
c. Increased incidence of pain twice or more compared to previous period within hours,
days or weeks by type of illness.
d. The number of new patients within a period of 1 (one) month shows an increase of
two or more times compared with the average number per month in the previous
year.
e. The average number of incidences of morbidity per month for 1 (one) year showed an
increase of two or more times compared with the average number of incidences of
morbidity per month in the previous year.
f. Case Fatality Rate (Case Fatality Rate) in 1 (one) period of time indicates an increase
of 50% (fifty percent) or more compared to the mortality rate of a disease case of the
previous period in the same period.
g. Proportional rate of new patient in one period shows increase twice or more
compared to one previous period in the same period.
(Permenkes, 2010)

c. What are the steps to conduct an outbreak investigation?

Answer:
According to Regulation of the Minister of Health of the Republic of
Indonesia No 949 / MENKES / SK / VIII / 2004, Investigation of alleged outbreaks by:
1) In the Health Service Unit, the health worker asks every visitor of the Health Service
Unit about the possibility of an increase in the number of people suspected of the
outbreak at a particular location.
 2) In the Health Services Unit, the health worker checks the inpatient and outpatient
registers of any possible increase in suspected cases at a particular location based on
the patient's address, age, and gender or other characteristics.
3) The health worker interviewed the village head, the head of the dormitory and
everyone who knows the state of the community about the increase of the suspected
disease of the outbreak.
4) Opening of service post at the location of suspected outbreak and analyzing patient
data of treatment to know the possibility of existence of increase of suspected
disease.
5) Visiting suspected persons home or home-to-house visits to all residents depending
on the choice of investigation team.

d. What the goals to investigate outbreaks?

Answer:
e. How to prevent disease transmission and provide health education in the community?
Answer:
1. Primary prevention.
Primary prevention is the effort to modify risk factors or prevent the development of
risk factors, before the start of pathological changes, performed at the stage of
suseptibel and disease induction, with the aim of preventing or delaying the occurrence
of new cases of disease.

2. Secondary prevention.
Secondary prevention is a preventive effort in the asymptomatic disease phase,
precisely at the preclinical stage, on the incidence of clinical disease symptoms through
early detection (early detection).
3.Terertial prevention.
Tertiary prevention is the prevention of disease progression in the direction of the
consequences of worse disease, with the aim of improving the quality of life of patients.
 Tertiary prevention is usually done by doctors and a number of other health professions
(eg, physiotherapists) (Depkes RI, 1994).

5. How is Islam's view related to this case?

Answer:
The Word of Allah SWT in Q.S. Ar-Ruum, 30: 41:

Meaning: "It has been seen that the damage on land and at sea is due to the deeds of
human hands; God wants them to feel some of the (result) of their deeds due to) their
deeds, in order that they return to the right path. "

Conclusion

Residents around the river Beringin Jaya Village pollute the river by bathing,
washing, and defecating and clearing land by burning the forest, thus increasing the
incidence of diarrhea and ISPA.

Conceptual Framework

Factory wasted flowed into

Burn Forest
river without prior treatment

Smoke Pollution Polluted water

Water used by residents for

ARI
vathing, washing, and
defecating

Polluted water

Diarrhea