BLOCK CBP

SEMESTER IStadium Generale and HumanioraMedical CommunicationThe Cell as Biochemical MachineryGrowth and Development Prenatal and Postnatal

SEMESTER IIMedical ProfessionalismCommunity-Based PracticeHealth System-Based PracticeEvidence-Based Medical PracticeSpecial TopicElective Study 1

SEMESTER IIIThe Hematologic System and Disorders and Clinical OncologyImmune System and Disorders

SEMESTER IVThe Musculoskeletal System and Connective tissue DisordersNeuroscience and Neurological DisordersBehavior Change and DisordersThe Visual System and Disorders

SEMESTER VThe Alimentary and Hepatobiliary System and DisordersThe Endocrine System, Metabolism, and DisordersClinical Nutrition and DisordersSpecial TopicElective Study 2

SEMESTER VIThe Respiratory System and DisordersThe Cardiovascular System and DisordersThe Urinary System and DisordersThe Reproductive System and Disorders

SEMESTER VIIMedical EmergencySpecial Topic: Travel MedicineElective Study 3

Tahun lalu dilakukan perdebatan di Stasiun TV Swasta Nasional dalam acara Indonesia Lawyers Club (ILC) yang membahas UU Pembatasan Penggunaan Tembakau antara kelompok yang anti dan yang proHampir semua kelompok anti UU mengemukakan alasan sbb: Ah, tidak benar merokok ada kaitannya dengan kanker paru-paru. Buktinya, saya dan teman-teman saya adalah perokok berat, dan sudah merokok selama 30 tahun, toh sampai saat ini tetap sehat-sehat saja. Pertanyaan: sebagai calon dokter apa komentar Sdr. dengan mengacu pada prinsip-prinsip CBP

APPROCHES OF CBP Prevention (not curative) Community (not individual)

Susceptible (at risk)Primary prevention Health promotion Specific protectionPresym-tomatic stageSecondary prev. Early detection & prompt treatmentClinical stageStage of dis- abilityTertiary prev. Disability limitation RehabilitationGeneticEnvironmentBehaviorHealth ServicesPhysicalSocial, culturalBiological, economicalDeterminants

1. Selama kuliah HP dimatikan (bukan silent) TATA TERTIB2. Dalam pleno pagi bila terlambat > 10 menit (jam di dinding ruang kuliah) mahasiswa tidak diperkenankan ikut kuliah

BLOCK CBP(Community-based Medical Practice) 1. HP harus dimatikan selama kuliah dan SGD2. Study Guide dan semua references agar selalu dibawa saat kuliah, SGD, individual learning3. Kehadiran dan keaktifan saat SGD dinilai (5% dari nilai ujian) INGAT ABSEN4. Kehadiran saat kuliah dan feedback dihitung (bila lebih dari 25% tidak ikut) tidak bisa ujianRULE/REGULATIONS

5. Pada saat plenary mahasiswa presentasi 6. Wakil mahasiswa yang presentasi harus dipilih pada saat SGD dan bukan di ruang kuliah 7. Wakil mahasiswa yang presentasi harus bergilir (tidak boleh sama pada setiap hari) 8. Sesaat sebelum plenary dimulai, wakil masing-masing kelompok yang akan presentasi langsung duduk didepan9. Narasumber akan memberi feedback pada presentasi mahasiswa

REFERENCES & MANUAL Study Guide & Annexes Reference 1-6 ManualPlease refer to each day session/module

DAY 1, 2, 3: MODULE-1CURRICULUM STUDY GUIDE 17 MODULESLEARNING MATERIALS: Reference 1 and 2 ,movie, video clip, websites (it is advice to download materials from the websites before the lecture)

Learning Outcomes: Describe several determinants (models) of diseases and death occurring in the population Explain the applications of understanding diseases and death determinants (models) Identify the strengths and weaknesses of diseases models Draw figure of the natural history of a certain disease

Explain the applications of the natural history of a disease for prevention Explain the severity of diseases in a population and its implication to prevention Describe the level of disease prevention based on determinants and natural history Explain the Ice Berg Phenomenom and its implication in diseases prevention

LEARNING SCHEDULE (time table) 08.00-09.00: Introductory lecture STUDY GUIDE PAGE 7 (CLASS B) 09.00-11.00: Independent learning Reference 1 & 2 Learning tasks page 18-21 11.00-13.00: SGD 14.00-15.00: Student presentation & feedback

LEARNING SCHEDULE (time table) 09.00-10.00: Introductory lecture STUDY GUIDE PAGE 11 (CLASS A) 10.00-12.00: Independent learning Reference 1 & 2 Learning task-1 & 2 page 18-21 13.00-15.00: SGD 15.00-16.00: Student presentation & feedback

APPROCHES OF CBP Prevention (not curative) Community (not individual)

Some of the people need health care some of the timeBUTAll of the people need public health all of the time."

C. Everett Koop, MD former U.S. Surgeon General

Determinants of morbidity and mortality in a population Natural history of the disease Diseases prevention MODULE-1

DAY 1 Determinants of morbidity and mortality in a population

The Epidemiologic Triad/ Triangle (Teori Segi Tiga) page 26 33 Wheel Model (Teori Roda) page 35-39 Web Model (Teori Sarang Laba-laba) page 33 Model Blum Several models/concept used to analyzed determinants of morbidity and mortality in a population Model Mosley

HOST (intrinsic) (age, sex, genotype, behaviour, nutritional status)

AGENT(biologic, physic, mechanical, chemical, nutrient)ENVIRONMENT (Physical, Biological, Social)Model Segitiga (The Epidemiologic Triad/ Triangle)

Triad epidemiologikAGENTBiological, chemical, physical Mechanical, NutrientHUMAN HOSTAge, race, sex, habitGenetic, personalityDefense mechanismENVIRONMENTBiological, chemical, physicalMechanical, nutrient, social, psychologic

Triad epidemiologik

Homeostatic Balance

GeneticHOSTEXTERNAL (extrinsic)INTERNAL (intrinsic)Physical EnvironmentSocial politic, economic cultureBiological Environ-mentModel Roda (Wheel Model)

Contoh Kasus Kematian IbuModifikasi dari: FA Moeloek, 2010WEB MODEL (SARANG LABA-LABA)

BLUM MODELMorbidity and mortality in a populationEnvironmental factors (biological, physical, social, economical, politic)Health servicesGeneticBehavior

CONCEPT (THEORY, MODEL)INTRODUCED BY DR. MOSLEY WHICH EXPLAINEDDETERMINANTS OF MORBIDITY ANDMORTALITY OF CHILDREN AGEUNDER 5 YEARS IN A POPULATION

SOCIAL DETERMINANTS OF HEALTH

WHO- CSDH conceptual framework

UNDERSTANDING CAUSALITY

Four types of Causal relationshipsNecessary and SufficientNecessary but not SufficientSufficient but not NecessaryNeither Sufficient nor Necessary

Necessary = without that factor disease never developsSufficient = in the presence of that factor disease alwaysdevelops

1. Necessary and Sufficient

Direct: Factor A Disease

Indirect: Factor A Step1 Step2Disease

rarely happens

2. Necessary but not Sufficient

Factor A +Factor BDisease +Factor C

Multiple factors required: initiator & promoter (cancer, TB)

3. Sufficient but not Necessary

Factor A orFactor BDisease orFactor C

Leukemia = Exposure to radiation OR benzene

4. Neither sufficient nor necessary(contributory causes)

Factor A + Factor B orFactor C + Factor D Disease orFactor E + Factor F

Most accurately represents causal relationships in most chronic diseases

END OF DAY 1

Plenary day 1Please refer to the plenary day 1 slides

DAY 2

Determinants of morbidity and mortality in a population Natural history of the disease Diseases prevention MODULE-1

DAY 2 Natural history of the diseaseDisease prevention

Natural History of DiseaseNatural history of disease: progression of disease in an individual over time WITHOUT any intervention.

NATURAL HISTORY OF THE DISEASE Page 6-9 reference 2 Four stages Stage of susceptibility (population at risk) Stage of pre symptomatic (asymptomatic) disease Stage of clinical (symptomatic) disease Stage of disability Every disease has difference natural history (example: HIV/AIDS, DHF)

Stage of susceptibility (population at risk)

Determinants (risk factors) (+), disease (-)TiredHigh cholesterol, high sugar, low fiberSmokingMultiple partners with unprotected sexSharing needleLow physical activity

Stage of pre symptomatic (asymptomatic) diseaseDisease (+), signs (+/-) symptoms (-)AteroscleroticAntibodi (+)Pre-cancer lesionLab marker >>>Uric acid, fasting glucose, LDL >>, creatinin >>

Stage of clinical (symptomatic) disease

Disease (+), signs and symptoms (+)Anatomical & functional changes (+)Grouping:SymptomsFunctional classLocalisation4. Morfologic/ cell type5. Theraphy

Ex:Cancer stadiumHearth disease Functional classtherapy

REASON OF THE GROUPING:Therapeutic reasonEpidemiological reason (homogenity, specific rate)

High relationship

Stage of disability

Disease outcomeTotal recovery (treatment, self limited)Partly recoveryScuele (+); disabilityPhysical (anatomical)SocialPhsycological

Perjalanan Alamiah Penyakit*PREPATOGENESISPATOGENESIS

Agen Host Fase klinis

Sembuh CacatLingkunganFase penyembuhan Mati Kronis

Fase susceptible Fase subklinis

Perjalanan Alamiah Penyakit

Natural history of diseaseSusceptiblehost

MeninggalKhronisCarrierSembuh dengan cacatSembuh tanpa cacatAsymptomatic stageSymptomatic stageNATURAL HISTORY (PERJALANAN PENYAKIT)Contoh: hepatitis

02001000 0 1 2 3 4 5 1 2 3 4 5 6 7Jumlah CD4BulanTahunPerjalanan infeksi HIVJumlah CD4Viral LoadInfeksi AkutInfeksi asimtomatikSimptomatik/AIDSWindow periodSerokonversi

Prevention can be done when determinants and natural history of the disease are understoodLEVEL OF PREVENTIONS IN BROAD CONCEPT Primary prevention Health promotion Behavior change education Policy/regulation Specific protection (specific to a certain disease)

Secondary prevention Early detection and prompt treatment/action Tertiary prevention Disability limitation Rehabilitation Medical Psychological Social EconomicalProlonging life/increase quality of life

Susceptible (at risk)Primary prevention Health promotion Specific protectionPresym-tomatic stageSecondary prev. Early detection & prompt treatmentClinical stageStage of dis- abilityTertiary prev. Disability limitation RehabilitationGeneticEnvironmentBehaviorHealth ServicesPhysicalSocial, culturalBiological, economicalUsing Blum Model/Concept

Natural History of Disease and Level of Prevention

Riwayat Alamiah Penyakit*

Riwayat Alamiah Penyakit

ICE-BERG PHENOMENA SEVERITY OF DISEASES

ICE BERG PHENOMENA (FENOMENA GUNUNG ES)

TWO CONSEQUENCIES(DUA KONSKUENSI)Semakin lebar dasar gunung es:Semakin sulit penanggulangan penyakit (control of the disease)Bila memakai data sekunder, data (statistik penyakit) akan semakin tidak akuratCONTOH: DBD dan RABIES

Epidemiological IcebergOnly the tip of the iceberg is easily observableDog bite example 3.73 dog bites annually451,000 medically treated334,000 emergency room visits13,360 hospitalizations20 deaths

THE VARIATION OF SYMPTOMATIC DISEASES SEVERITY100 CASESMild (ringan)ModerateSevereFatal

The film presentation showed to youContribution (peran) of: scientific foundations, clinical skill, communication skill, information management, critical thinking, professional values and attitudes, community healthMeneliti kausa suatu penyakit (AIDS) dan pencegahannya

DIFFERENCES BETWEENPUBLIC HEALTH DOCTORCLINICAL DOCTOR

1. Focus: population2. Responsibilities: all people in certain geographical area, health and sick, those who come and those who do not come to health facilities. They must actively provide diseases prevention to all people who are at risk 1. Focus: individual2. Responsibilities: all people who come to the health facilities. They usually passive.

PUBLIC HEALTH DOCTORCLINICAL DOCTOR

3. Function: to mobilize all stakeholders and using management principles to plan, implement and evaluate primary, secondary, tertiary preventions 3. Function: to cure and to increase the patients quality of life 4. Place of works: health centre, heath department, community clinics, etc 4. Place of works: private practices, hospitals, etc

PUBLIC HEALTH DOCTORCLINICAL DOCTOR

5. Diagnostic tools: epidemiology, statistics, demography 5. Diagnostic tools: stethoscope, ECG, lab examinations kits , CT Scan, etc 6. Diseases measurements in the community: proportion, prevalence, incidence, ratio 6. Diseases measurements for individual patient: level of blood pressure, blood sugar, level of hemoglobin, etc

PUBLIC HEALTH DOCTORCLINICAL DOCTOR

7. Treatment at the community level (prevention): public health program such as education program, immunization program, nutrition program, family planning program, etc 7. Treatment for individual patient (diagnosis and care): medical treatments, surgery, radiation, physiotherapy, etc

PUBLIC HEALTH DOCTORCLINICAL DOCTOR

8. Indicators for evaluating community health program: percent decrease of under nutrition, percent increase of contraceptive use for family planning, etc 8. Indicators for evaluating the result of patients treatments: decrease of blood pressure of the individual patient, increase of hemoglobin

FIVE STARS DOCTOR (WHO = World Health Organization) Care provider (clinical dr) Communicator (clinical & PH dr) Manager (PH dr) Community leader (PH dr) Decision maker (clinical & PH dr)

SOAL-SOAL PEMANASAN SEBELUM UJIAN

As shown in the film And The Band Played On which was presented to you, there were several sciences involved in investigation the cause of AIDS. Those sciences are:A. Social, economic, politic, epidemiology, statistic, virology, clinical medicineB. Social, politic, epidemiology, statistic, virology, clinical medicine, health educationC. Social, epidemiology, statistic, virology, clinical medicine, health educationD. Clinical medicine, epidemiology, statistic, social, politicE. Social science, epidemiology, statistic, virology, clinical medicine

Dalam film dengan judul And The Band Played On yang telah Sdr. saksikan pada waktu pertemuan pertama Blok Community-Based Practice, ada beberapa metode yang dipergunakan untuk mengungkapan penyebab AIDS, yaitu:

1. Contact tracing2. Cohort3. Case-control4. Cross-sectional

Bila dilihat dari waktunya, urutan cabang ilmu yang membantu mengungkapan penyebab AIDS, yaitu:

A. Paling awal virologi, lalu epidemiologi dan terakhir ilmu klinik B. Paling awal ilmu klinik, lalu virologi dan terakhir epidemiologiC. Paling awal ilmu klinik, epidemiologi/statistik/ilmu sosial, lalu virologiD. Paling awal virologi, statistik/epidemiologi lalu ilmu klinikE. Paling awal statistik/epidemiologi, ilmu klinik lalu virologi

Pada Gambar-1 berikut ini adalah kompetensi (kemampuan) yang harus dikuasai oleh seorang dokter. Kompetensi untuk memahami statistik kasus-kasus AIDS dalam film dengan judul And The Band Played On termasuk:

1. Scientific foundations2. Information management3. Professional values4. Population health

Critical thinkingInformation managementCommunication skillCommunity Health (Pu-blic Health)Clinical skillProfessional, values, attitudesScientific foundationsCBP

Salah seorang mahasiswa (inisial X) yang kuliah di fakultas non-kesehatan mengatakan sebagai berikut: Ah, tidak benar merokok ada kaitannya dengan kanker paru-paru. Buktinya, paman saya adalah perokok berat, dan sudah merokok selama 30 tahun, toh sampai saat ini dia sehat-sehat saja. Pertanyaan: berikan komentar Sdr. terhadap pernyataan mahasiswa X seperti pada soal di atas (dengan mengacu pada prinsip-prinsip epidemiologi).

Lho, kenapa pelacur yang sudah jelas-jelas dijumpai HIV+ tidak dikarantina. Mereka ..kan dengan bebas masih menularkan HIV-nya pada orang lain. Kenapa pada saat terjadi wabah SARS, yang dicurigai saja sudah langsung diisolasi? Dalam suatu program interaktif yang membahas topik wabah HIV/AIDS di sebuah stasiun radio di Bali, banyak pendengar dengan berapi-api mengatakan melalui telepon sebagai berikut:

Anggota DPRD Provinsi Bali tahun lalu mengatakan sebagai berikut: Kami sudah mengalokasikan dana APBD yang cukup besar untuk penanggulangan HIV/AIDS di Bali. Kenapa jumlah orang yang HIV+/AIDS kok terus bertambah banyak. Harusnya kan berkurang. Kalau begitu percuma dana yang kami alokasikan tersebut. PERTANYAAN: Seandainya Sdr. menjadi petugas kesehatan, bagaimana Sdr. menjawab pernyataan anggota DPRD tersebut

Tempat tidur pasien demam berdarah yang dirawat di rumah sakit kok tidak pakai kelambu? Kalau pasien digigit nyamuk Aedes kan bisa menularkan penyakitnya kepada petugas di RS atau kepada pasien lain?Pertanyaan pendengar dalam program interaktif di sebuah stasiun radio di Bali

*Always multifactors never single factor

Sebelum tahu etiologi, kita harus tahu faktor2 nya juga

Rokok:TV one Saudara sebagai wakil menkes apa yang dipakai me Apakah orang merokok pasti kena kanker? Pakai persentase, insiden, Host agen environmentKolera kuman kolera tidak semua sakit100 merokok tidak semua kenaPembanding, yang sehat, yang mati bagaimana? Pasien profile di refernce

**Penyakit adalah hasil dari kekuatan dalam suatu sistem dinamik yang terdiri dariAgen infeksiManusia (host)LingkunganPada penyakit menular terjadi interaksi antara : agent (living agent) host environment

Pada penyakit tidak menular terjadi interaksi antara : agent (non living agent) host environmentAgent dapat berupa elemen,substansi atau suatu kekuatan(force) benda mati ataupun benda hidupagen biologis bakteri, fungi, parasit, virus agen fisik tekanan atmosfer, temperatur, kelembaban, radiasi dll

agen mekanik gaya mekanik spt sayatan, penetrasi, sobekan, peregangan dll

agen kimiawi bahan kimiawi eksogen ( gas-gas berbahaya, zat toksik) bahan kimiawi endogen (dari tubuh sendiri misal uremia)

agen nutrien KH, lemak, protein, vitamin, mineral, ai*Never single factor always multifactorsInteraction and connectivities between factors**Mosley ***Chapter 2: General Concepts*Epidemiology**Chapter 2: General Concepts*Epidemiology**