Anis Fuad

Progress towards malaria elimination in Sabang Municipality, Aceh, Indonesia

BackgroundIndonesia has set 2030 as its deadline for elimination of malaria transmission in the archipelago, with regional deadlines established according to present levels of malaria endemicity and strength of health infrastructure. The Municipality of Sabang which historically had one of the highest levels of malaria in Aceh province aims to achieve elimination by the end of 2013.MethodFrom 2008 to 2010, baseline surveys of malaria interventions, mapping of all confirmed malaria cases, categorization of residual foci of malaria transmission and vector surveys were conducted in Sabang, Aceh, a pilot district for malaria elimination in Indonesia. To inform future elimination efforts, mass screening from the focal areas to measure prevalence of malaria with both microscopy and PCR was conducted. G6PD deficiency prevalence was also measured.ResultDespite its small size, a diverse mixture of potential malaria vectors were documented in Sabang, including Anopheles sundaicus, Anopheles minimus, Anopheles aconitus and Anopheles dirus. Over a two-year span, the number of sub-villages with ongoing malaria transmission reduced from 61 to 43. Coverage of malaria diagnosis and treatment, IRS, and LLINs was over 80%. Screening of 16,229 residents detected 19 positive people, for a point prevalence of 0.12%. Of the 19 positive cases, three symptomatic infections and five asymptomatic infections were detected with microscopy and 11 asymptomatic infections were detected with PCR. Of the 19 cases, seven were infected with Plasmodium falciparum, 11 were infected with Plasmodium vivax, and one subject was infected with both species. Analysis of the 937 blood samples for G6PD deficiency revealed two subjects (0.2%) with deficient G6PD.DiscussionThe interventions carried out by the government of Sabang have dramatically reduced the burden of malaria over the past seven years. The first phase, carried out between 2005 and 2007, included improved malaria diagnosis, introduction of ACT for treatment, and scale-up of coverage of IRS and LLINs. The second phase, from 2008 to 2010, initiated to eliminate the persistent residual transmission of malaria, consisted of development of a malaria database to ensure rapid case reporting and investigation, stratification of malaria foci to guide interventions, and active case detection to hunt symptomatic and asymptomatic malaria carriers.

Early malaria resurgence in pre-elimination areas in Kokap Subdistrict, Kulon Progo, Indonesia

BackgroundIndonesia is among those countries committed to malaria eradication, with a continuously decreasing incidence of malaria. However, at district level the situation is different. This study presents a case of malaria resurgence Kokap Subdistrict of the Kulon Progo District in Yogyakarta Province, Java after five years of low endemicity. This study also aims to describe the community perceptions and health services delivery situation that contribute to this case.MethodsAll malaria cases (2007–2011) in Kulon Progo District were stratified to annual parasite incidence (API). Two-hundred and twenty-six cases during an outbreak (May 2011 to April 2012) were geocoded by household addresses using a geographic information system (GIS) technique and clusters were identified by SaTScan software analysis (Arc GIS 10.1). Purposive random sampling was conducted on respondents living inside the clusters to identify community perceptions and behaviour related to malaria. Interviews were conducted with malaria health officers to understand the challenges of malaria surveillance and control.ResultsAfter experiencing three consecutive years with API less than 1 per thousand, malaria in Kokap subdistrict increased almost ten times higher than API in the district level and five times higher than national API. Malaria cases were found in all five villages in 2012. One primary and two secondary malaria clusters in Hargotirto and Kalirejo villages were identified during the 2011–2012 outbreak. Most of the respondents were positively aware with malaria signs and activities of health workers to prevent malaria, although some social economic activities could not be hindered. Return transmigrants or migrant workers entering to their villages, reduced numbers of village malaria workers and a surge in malaria cases in the neighbouring district contributed to the resurgence.ConclusionCommunity perception, awareness and participation could constitute a solid foundation for malaria elimination in Kokap. However, decreasing number of village malaria workers and ineffective communication between primary health centres (PHCs) within boundary areas with similar malaria problems needs attention. Decentralization policy was allegedly the reason for the less integrated malaria control between districts, especially in the cross border areas. Malaria resurgence needs attention particularly when it occurs in an area that is entering the elimination phase.

Change of strategy is required for malaria elimination: a case study in Purworejo District, Central Java Province, Indonesia

BackgroundMalaria has been targeted for elimination from Indonesia by 2030, with varying timelines for specific geographical areas based on disease endemicity. The regional deadline for malaria elimination for Java island, given the steady decrease of malaria cases, was the end of 2015. Purworejo District, a malaria-endemic area in Java with an annual parasite incidence (API) of 0.05 per 1,000 population in 2009, aims to enter this elimination stage. This study documents factors that affect incidence and spatial distribution of malaria in Purworejo, such as geomorphology, topography, health system issues, and identifies potential constraints and challenges to achieve the elimination stage, such as inter-districts coordination, decentralization policy and allocation of financial resources for the programme.MethodsHistorical malaria data from 2007 to 2011 were collected through secondary data, in-depth interviews and focus group discussions during study year (2010–2011). Malaria cases were mapped using the village-centroid shape file to visualize its distribution with geomorphologic characteristics overlay and spatial distribution of malaria. API in each village in Purworejo and its surrounding districts from 2007 to 2011 was stratified into high, middle or low case incidence to show the spatiotemporal mapping pattern.ResultsThe spatiotemporal pattern of malaria cases in Purworejo and the adjacent districts demonstrate repeated concentrated occurrences of malaria in specific areas from 2007 to 2011. District health system issues, i.e., suboptimal coordination between primary care and referral systems, suboptimal inter-district collaboration for malaria surveillance, decentralization policy and the lack of resources, especially district budget allocations for the malaria programme, were major constraints for programme sustainability.ConclusionsA new malaria elimination approach that fits the local disease transmission, intervention and political system is required. These changes include timely measurements of malaria transmission, revision of the decentralized government system and optimizing the use of the district capitation fund followed by an effective technical implementation of the intervention strategy.

High rate EHR adoption in Korea and health IT rise in Asia.

We appreciate the work of Yoon et al. reporting EHR adopion in Korean hospitals [1]. By adopting a questionnaire which as been implemented in US, their findings allowed them to laim that the adoption rate of electronic health record (EHR) nd computerized physician order entry (CPOE) by Korean ospitals was higher than in US [2]. It is truly a promising perormance of Korean health IT, and perhaps inspiring for other ountries in the region. Is it an early sign of health IT rise in sia? In the next decade, China is predicted to overtake US to eign the world economy. Optimistic outlook also favors to the even leading countries in Developing Asia including China, ong Kong, India, Indonesia, Singapore, South Korea, and aiwan [3]. It is assumed that economic growth will drive more ealth IT investment. Developed income countries in this egion have reported some levels of EHR adoption [4,5]. Howver we are lacking of comparable documentation from the emaining countries, especially the lowand middle-income ountries in this region. The key to bring this debate into the right direction is he availability of instrument which accommodates not only ommon understanding of EHR concept but also the transiion process toward EHR adoption, particularly for lowand iddle-income countries. Therefore, we propose to add two ore levels: “basic IT” and “pre EHR” besides the two existing unctionalities: “basic EHR” and “comprehensive EHR”. Combiation with global secondary data for example income country evel, Network Readiness Index by World Economic Forum, ountry health profiles and Millennium Development Goals ndicators could produce a metric to measure EHR situation n this region. WHO has ever initiated global e-health surveys ut with different approach [6]. This letter aims to start the discourse in the context of coninuously changing global environment. Limited biomedical nformatics publications from this region, compared to US and urope, should drive a strengthened regional synergies and ollaboration. The complicated challenge is that while there re some countries indicated as health IT pioneers, but many are in its infancy stage to adopt. Since the seventh congress of Asia Pacific Association of Medical Informatics (APAMI) will be held in Beijing on October this year, therefore we call for the conference organizer not to overlook this crucial issue. A long term agenda to monitor the rise of health IT in Asia is urgently waiting to be elaborated.

GIS for Dengue Surveillance: Strengthening Collaborations

Dear Sir: We congratulate Duncombe and colleagues1 for their interesting review concerning the role of the geographic information system (GIS) for dengue surveillance. They provide examples, particularly from the developing countries, showing the various functions of GIS to automate spatial identification, visualization, analysis, and decision making aiming to assist dengue-related public health actions. Despite the challenges, the authors advocate the use of open access technologies and international collaboration to improve dengue surveillance at the sub-national, country, and regional levels. Although we agree with the international collaboration proposition, on the contrary, we doubt that this initiative alone could lead to improvement of dengue surveillance at a sub-national level. Incomplete data and untimely reporting are the main challenges to surveillance systems in developing countries. Although the authors mention some technical challenges confronted by developing countries, they do not sufficiently recognize issues in their individual health systems,2 particularly decentralization policies, which interfere with comprehensiveness and accuracy of surveillance systems. Indonesia and the Philippines are among the dengue-burdened countries that have decentralized various health policies in the last decade, leading, in our view to at least three anecdotal phenomena. First, until well established, decentralization policy leads to structural and regional changes. Elimination, formation, amalgamation, and expansion of regions have problems in initial implementation, for example in causing troublesome spatial data processing and analyses. Second, more autonomous authority in the lower level has initiated idiosyncratic local rules and procedures. Unfortunately, national policies have not been implemented with decentralization of procedures and data collection/exchange. Third, policy makers at the national level are still confronted with inequities and gaps among regions in terms of human resources, fiscal capacity, local health problems, and infrastructures (including information and communication technologies) when commencing this reform. Finally, recommendations to foster international collaboration for GIS dengue surveillance should be balanced with efforts to strengthen surveillance capacity at national and subnational levels, particularly with regard to standard data collection, exchange and sharing.

Google Trends Data on Dengue (Indonesia)

Digital traces are rapidly used for health monitoring purposes in recent years. This approach is growing as the consequence of increased use of mobile phone, Internet, and machine learning. Many studies reported the use of Google Trends data as a potential data source to assist traditional surveillance systems. The rise of Internet penetration (54.7%) and the huge utilization of Google (98%) indicate the potential use of Google Trends in Indonesia. Since no previous study exists on validating official dengue reports and Google Trends data in Indonesia and comparing them over time, this study aimed to cover this gap. This research was a quantitative study using time series data (2012-2016). Two sets of data were validated using Moving Average analysis in Microsoft Excel. Pearson and Time lag correlations were also used to measure the association between those data. Moving Average analysis showed that Google Trends data have a linear time series pattern with official dengue report. Pearson correlation indicated high correlation for 3 defined search terms with R-value range from 0.921 to 0.937 (p≤0.05, overall period) which showed increasing trend in epidemic periods (2015-2016). Time lag correlation also indicated that Google Trends data can potentially be used for an early warning system and novel tool to monitor public reaction before the increase of dengue cases and during the outbreak. Google Trends data have a linear time series pattern and statistically correlated with annual official dengue reports. Identification of information seeking behavior is needed to support the use of Google Trends for disease surveillance in Indonesia.

Ten-years trend of dengue research in Indonesia and South-east Asian countries: a bibliometric analysis

ABSTRACT Background: Dengue fever is a mosquito-borne viral disease with high incidence in over 128 countries. WHO estimates 500,000 people with severe dengue are hospitalized annually and 2.5% of those affected die. Indonesia is a hyperendemic country for dengue with an increasing number of cases in the last decade. Unfortunately, the trends of Indonesian dengue research are relatively unknown. Objective: This research aimed to depict bibliographic trends and knowledge structure of dengue publications in Indonesia relative to that of South-east Asia (SEA) from 2007 to 2016. Methods: Bibliographic data were collected from PubMed filtered by Indonesia country affiliation. The annual growth rate of publication was measured and compared with neighborhood countries in the SEA region. Network analysis was used to visualize emerging research issues. Results: About 1,625 dengue-related documents originated from SEA region, of which Indonesia contributed 5.90%. The publication growth rate in Indonesia, however, is the highest in ASEAN region (28.87%). Total citations for documents published from Indonesia was 980, with an average of 14 citations per publication and h-index of 16. Within the first five years, the main research topics were related to insect vector and diagnostic method. While insect vector remained dominant in the last five years, other topics such as disease outbreak, dengue virus, and dengue vaccine started emerging. Conclusion: In the last 10 years, dengue publications’ growth from Indonesia in international journals improved significantly, despite less number of publications compared to other SEA countries. Efforts should be made to improve the quantity and quality of publications from Indonesia. The research topics related to dengue in Indonesia are in line with studies in SEA. Stakeholders and policy makers are encouraged to develop a roadmap for dengue research in the future.

UTAUT for HSS: initial framework to study health IT adoption in the developing countries

Unified Theory of Acceptance and Use of Technology (UTAUT) is an integrative concept that has been used widely to measure IT adoption. However, a recent study in a developing country concluded that UTAUT is not adequate in predicting IT adoption within the context of health system strengthening (HSS). It has been suggested that context-specific dimensions to modify UTAUT should be considered. The objective of this paper is to propose an extension of the theory, called UTAUT for HSS, as a reference for contextualizing health system variables for health IT adoption studies in the developing countries. We combined the multi-level framework of UTAUT with WHO health system building blocks. Modification of the original multi-level framework was performed on the 3 levels. i.e: the higher-level contextual factors, middle-level, and individual-level contextual factors. Based on this, we propose a modified multi-level framework of technology acceptance and use for health system strengthening setting (UTAUT for HSS). Given the complexities of health systems, more thoughts regarding the methodologies will be useful to enrich this initial framework. Commentaries and discussions are invited for improvement, before implementation to obtain more complete story of health IT adoption in the low resources setting.

Pola Spasial-Temporal Epidemi Demam Chikungunya dan Demam Berdarah Dengue di Kota Yogyakarta Tahun 2008

Spatial-Temporal Pattern Comparison Between Chikungunya Outbreak And Dengue Hemmorhagic Fever Incidence At Kota Yogyakarta 2008 Background: Explosive re-emergence of chikungunya fever has been started since 2004 and affected millions people in worldwide i.e. Indian Ocean, India, Europe, Asia including Indonesia. On January 2008, 59 new cases of chikungunya fever was reported by the Kota Yogyakarta health office meanwhile the province laboratory had no capability to perform laboratory examination to confirm the diagnosis. Control measures were already taken, but it seemed not effective, cases were spread and increased progressively by weeks and non-vector born disease which has similar sign and symptoms was thought to be the cause. Based on the same vector with dengue hemorrhagic fever transmission, an ecological approach using GIS was taken to compare the spatial-temporal pattern between chikungunya and DHF. Objective: The objective of this study was to compare the spatial-temporal pattern between chikungunya fever outbreak and dengue hemorrhagic fever incidence. Method: This study was use ecological study approach which uses integrated GIS, remote sensing and statistic technique. We collected total of 802 chikungunya and 498 dengue cases in ten months (November 2007 – August 2008) and secondary data on environmental variable includes population density, vegetation density, building density, land use, larvae index and climate. Location of cases was obtained using GPS. Epidemic curve were plotted to identify the disease trend. Space time permutation was used to identify disease clustering. Result: Temporal trend analysis show similarity pattern between chikungunya and DHF, increasing trend was found few weeks following heavy rain. There were positive correlations between diseases and population density, building density. Chikungunya and DHF cases were tended to occur in residential land use which close to the commercial land use. Spatial-temporal clustering was observed on both diseases demonstrating variation in local infection pattern. There was similarity on disease cluster occurrence between chikungunya and DHF Conclusion: We show spatial-temporal pattern similarity between chikungunya outbreak and dengue hemorrhagic incidence, nevertheless laboratory confirmation is important and should be provided. This study provides useful information for urban public health management. Further study is needed to develop model in vector born early warning system using GIS and remote sensing. Keywords: dengue, chikungunya, GIS, spatial-temporal pattern, environmental epidemiology