South to South Exchange Fellowship 2010 Activity Report

1 Introduction As tropical and developing countries, Cambodia and Indonesia may have similar health problems. Both countries could have the same disease patterns and challenges on resource availability. Soil transmitted helminthes (STH) infection and dengue are prevalent in Cambodia and Indonesia. Cambodia was mentioned as a country which is successful in protecting 100% of school children by regular antihelminthics. The political commitment to bear the costs to reach 100% coverage of antihelminthics has enabled the country to reach the target ahead of time(1). The effective control of schistosomiasis in Cambodia has dropped the prevalence drastically from 77% in 1995 to 0.5% in 2003(2). The universal coverage of antihelmintics to control schistosomiasis and soil transmitted helminthes infection has decreased the prevalence of soil transmitted helminthes infection in two endemic provinces significantly(3). Dengue control has been a long term activities in Indonesia. Gadjah Mada University has been conducting several trainings on dengue vector, diagnosis, and clinical management. Taking the opportunity of the South to South Exchange Fellowship, we have conducted some activities which enable public health researchers from Indonesia and Cambodia learn the STH and dengue control from each other. The objectives of the activities are:

1. To share the knowledge on successful NID control strategies from both countries:

a. Helminthiasis and schistosomiasis control strategies in Cambodia b. Dengue clinical management and control in Indonesia

2. To experience the neglected infectious disease ongoing research from both countries

3. To sensitize the general public about NID through Annual Scientific Meeting of Medical Faculty, Gadjah Mada University

2 Activities In the year 2010, we have conducted visit activities to the partner countries. In March, dr. Lek Disoley from Cambodia participated as speaker in Annual Scientific Meeting in Yogyakarta, Indonesia. In November dr. Bintari Dwihardiani and dr Elsa Herdiana from Indonesia visited Cambodia to learn soil transmitted helminthiasis control. In December, dr. Sam Ol Siv visited Indonesia to learn Dengue control.

2.1 Annual Scientific Meeting, Faculty of Medicine Gadjah Mada University, 6th march 2010

In Indonesia, the prevalent NIDs are soil transmitted helminthiasis, filariasis, leprosy, leptospirosis, frambusia, schistosomiasis, and taeniasis. The government has made

significant efforts to control schistosomiasis and filariasis. The commitment was shown by developing special units of schistosomiasis and filariasis under the disease control and environment health department in ministry of health. The control of other NIDs has been tempted but it was not without problems. As a result, some NIDs which were thought to be under control in some area re-emerge and become public health problems. Despite the high prevalence, some areas have not implemented the recommended control methods. The problems range from unawareness, lack of funding, and lack of strong policies to guide the acts. The affected populations are also considered not having strong political position to advocate their problem to be in the political agenda. The seminar aims to sensitize the public on the burden of NIDs, so that concrete efforts will be organized to eradicate them. The target participants are: medical doctors, medical students, public health specialists, researchers, and health policy maker. The program consisted of presentations on current NID control activities in Indonesia in different level, the case management of several NIDs, the ongoing researches by students and researchers of Gadjah Mada University, and NIDs control situation in the international level. The complete program of the seminar can be seen in annex 1. Dr. Lek Disoley from Cambodia has participated in this program by presenting the STH and schistosomiasis control activity in Cambodia. His presentation can be seen in annex 2. Dr Lek Disoley was also invited to Parasitology Department of Gadjah Mada University to share Cambodia successful experience of STH control in details. His presentation can be seen in annex 3.

2.2 Visit Cambodia Dr. Bintari Dwihardiani visited Cambodia on 18th-25th november 2010 while dr. Elsa Herdiana did the visit on 28th november-6th December 2010. The objectives of the visit are:

1. Understanding the national helminthiasis control strategy 2. Understanding the ministry of health structure which related to helminthiasis

control 3. Understanding the implementation of helminthiasis control in district level:

the responsible person, the budget, the collaboration with other sectors, the integration of neglected disease control.

4. Understanding the other control method other than mass drugs administration As a country with centralized health system, health policies and management are controlled by central Ministry of Health. Inter-section collaboration for helminthiasis control is initiated in the national level both for policy and strategies making and implementation. Helminthiasis control was done through mass drugs administration (MDA) and case management. MDA was organized in collaboration with primary schools throughout the country twice a year. In the health center level, drugs distribution was integrated with other activities such as immunization and vitamin A distribution, in an outreach activity. Some drugs were provided by pharmaceutical companies: Johnson & Johnson and Glaxo Smith Kline.

The challenges faced are: lack of funding, lack of human resource especially in rural area, and re-infection because of lack of sanitation and hygiene facilities. The complete report of the visit to Cambodia can be seen in annex 4. Figure 1 dr. Elsa Herdiana, dr. Lek Disoley, with health center staffs

2.3 Visit Indonesia Dr. Sam ol Siv visited Yogyakarta on December 2010. The activities during the visit were:

1. Discussing and reviewing the differences of the Dengue Fever/ Dengue Shock Syndrome (DF/DSS) cases in Yogyakarta, Indonesia to Cambodia

2. Discussing recent publication/research of DF/DSS conducted by Gadjah Mada team

3. Learning to identify DF/DSS mosquito vector 4. Participating in the field visit together with parasitology department of

Gadjah Mada university, whose activities were: - meeting with the community - encourage and teach the community how to collect

mosquito larvae and pupae from wells and bathtub - demonstrating the tools created by Gadjah Mada University

to trap the larvae and pupae (funnel trap and vacuum pipe) - release Toxorhinicytes mosquitoes as biologic vectors in the

field

5. Learning how to rearing and breed mosquito vectors, including Toxorhinicytes sp , as Aedes sp biologic predator

Funnel trap, vacuum pipe, and modified pipette are tools modified by the staffs of parasitology department in Gadjah Mada University

Figure 2 vacuum pipe to trap mosquito larvae and pupae

3 Lesson Learnt The visit to Cambodia to learn helminthiasis control has enabled us to observe a model of intersection collaboration in the national level to control the disease. The health system in Indonesia is different than in Cambodia as it is decentralized in Indonesia with district autonomy. The model of collaboration in the national level in Cambodia could be adapted in district level in Indonesia. The dengue control activities are decentralized in Indonesia. The action to control an outbreak is decided in health center level. It allows rapid action. We learnt that both countries have the same challenges in general, which are the retention of human resource in the rural area and lack of funding. The integrated outreach program could help to rationalize the use of resource. The outreach model in Cambodia is almost the same as Indonesian integrated health post (posyandu) system. The health centers worker and community health workers in Indonesia organized monthly activities to deliver several services: immunization, vitamin A distribution, and child growth and development monitoring. Learning from Cambodia experience actually we could add deworming in the activities of integrated health post. The district collaboration model and integrated health post could be the subjects of NID operational research.

4 Recommendations As the exchange activities were very useful to enrich the researchers about NID control, it will be good to continue. It is good also to continue this exchange program between countries with the same health system so the researcher will learn something more adapted to their context. However, it is still a good learning even if the collaborative country has different health system.

5 Expenditure The complete report of expenditure can be seen in annex 5

Reference List

(1) World Health Organisation. Neglected tropical diseases: neglected tropical diseases, hidden successes, emerging opportunities. Geneva: World Health Organisation, 2009.

(2) Croce D, Porazzi E, Foglia E, Restelli U, Sinuon M, Socheat D et al. Cost-effectiveness of a successful schistosomiasis control programme in Cambodia (1995-2006). Acta Trop 2009.

(3) Sinuon M, Tsuyuoka R, Socheat D, Odermatt P, Ohmae H, Matsuda H et al. Control of Schistosoma mekongi in Cambodia: results of eight years of control activities in the two endemic provinces. Trans R Soc Trop Med Hyg 2007; 101(1):34-39.

ANNEX 1 – Programme NID seminar

Seminar on Neglected Infectious Diseases Annual Scientific Meeting, Universitas Gadjah Mada

6th March 2010 Senat Room, KPTU Building, Faculty of Medicine, Universitas Gadjah

Mada

Background Neglected infectious diseases (NIDs) refer to a group of tropical infections

which are endemic in low income populations in developing countries. The group consists of mainly chronic disabling infections, such as sleeping sickness, leishmaniasis, Chagas disease, human African trypanasomiasis, Buruli ulcer, leprosy, lymphatic filariasis, dracunculiasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis (ascariasis, trichuriasis and hookworm infection), dengue, trachoma, rabies and endemic zoonoses such as cysticercosis, trematodiasis or brucellosis.

In Indonesia, the prevalent NIDs are soil transmitted helminthes infection, filariasis, leprosy, leptospirosis, frambusia, schistosomiasis, and taeniasis. The government has made significant efforts to control schistosomiasis and filariasis. The commitment was shown by developing special units of schistosomiasis and filariasis under the disease control and environment health department in ministry of health. The control of other NIDs has been tempted but it was not without problems. As a result, some NIDs which were thought to be under control in some area re-emerge and become public health problems.

Despite the high prevalence, some areas have not implemented the recommended control methods. The problems range from unawareness, lack of funding, and lack of strong policies to guide the acts. The affected populations are also considered not having strong political position to advocate their problem to be in the political agenda. Objective The seminar aims to sensitize the public on the burden of NIDs, so that concrete efforts will be organized to eradicate them.

Target participants Doctors, medical students, public health specialists, researchers, Health policy maker

Programs:

I. Opening speech, Prof. Supargiyono, head of the center for tropical medicine, Medical Faculty, UGM (09.00-9.15)

II. Lecture notes: Towards the systematic control on neglected infectious diseases in Indonesia

Current situation on neglected diseases prevalence in Indonesia

Speakers: • National strategy on neglected diseases control in Indonesia: Dr.

Tjandra Yoga Aditama, SpP (Directorate General of Communicable Disease Control and Environmental Health, Ministry of Health Indonesia) (9.20-9.35)

• District level strategy on neglected diseases control in Indonesia: (CDC-EH of Yogyakarta) (09.35 – 09.50)

• Research activities on neglected diseases: Prof. Supargiyono (Center for tropical medicine), UGM: (09.50-10.05)

• Update on diagnostic and treatment of lymphatic filariasis, speaker: Prof. Soeyoko (10.05-10.20)

Has the attention on NIDs in Indonesia reached optimal level?

• Promoting local research on neglected infectious diseases in Indonesia based on national research mapping (dr. Elsa Herdiana, MKes, FM, UGM) (10.20-10.35)

Discussion (10.35-11.05)

III. Paper Presentation Four papers presentation (11.05—12.05):

1. Hutagalung J, Soeyoko, Fuad A Spatial analyses and risk factors for lymphatic filariasis, Agam District, Indonesia 2005-2009

2. Setiawan B, Soeyoko, Wibawa TA, Faktor risiko kejadian filariasis Malayi di wilayah kerja Puskesmas Cempaka Mulia, Sampit, Kalimantan Tengah tahun 2008

3. jjj 4. Mujiyanto et al. Pemetaan geospatial daerah endemis baru schistosomiasis

di dataran tinggi Bada, Sulawesi Tengah Indonesia 5. Anis NW, Ade K, Jastal, Sudomo M. Efektivitas ekstrak biji jarak

(jatropha gossypifolia L.) terhadap hospes perantara schistosomiasis (keong Oncomelania hupensis lindoensis) di Napu, Kabupaten Poso, Sulawesi Tengah

5.1 IV. Lunch break (12.20 – 13.20)

5.2 V. Seminar: Clinical Management on Neglected Infectious Disease

Management of frambusia and leprosy (Prof. Hardyanto, FM, UGM) (13.20-13.35)

Update on Management of Soil Transmitted Helminths infections (Dra Sri Sumarni, SU, DAP &E, Parasitology, FM UGM) (13.35-13.50)

Leptospirosis, diagnosis and treatment (Dra. Ning Rintiswati, MKes, Microbiology FM UGM and Dr. Yanri Subronto, SpPD, PhD) (13.50-14.20)

Discussion (14.20-15.00)

VI. End remark: International experience on advocacy for control of neglected infectious disease

• NID control experience in other developing country. Speaker: Lek Disoley, National center of Parasitology, Entomology, and Malaria Control, Cambodia, (15.00-15.15)

• Global advocacy for control of neglected infectious diseases. Speaker: WHO Jakarta (15.15-30)

• Discussion (15.30-16.00)

Annex 4

Visit Cambodia

South to South Collaboration Program Bintari Dwihardiani and Elsa Herdiana

Background Cambodia was mentioned as a country which is successful in protecting 100% of school children by regular antihelminthics. The political commitment to bear the costs to reach 100% coverage of antihelminthics has enabled the country to reach the target ahead of time(1). The effective control of schistosomiasis in Cambodia has dropped the prevalence drastically from 77% in 1995 to 0.5% in 2003(2). The universal coverage of antihelmintics to control schistosomiasis and soil transmitted helminthes infection has decreased the prevalence of soil transmitted helminthes infection in two endemic provinces significantly(3). In Indonesia, the prevalence of soil transmitted helminthiasis in rural area is still high. According to the national prevalence survey which was conducted end of 2009 by the ministry of health, there are provinces with the helminthiasis prevalence more than 50%, for example in Maluku province(4). Despite the guideline issued by the Ministry of Health, the helminthiasis control activities in this area are not conducted properly. Based on this fact, and using the opportunity of south to south collaboration, we conduct the visit to Cambodia to learn better about the helminthiasis control strategy.

Objectives 1. Understanding the national helminthiasis control strategy 2. Understanding the ministry of health structure which related to helminthiasis control 3. Understanding the implementation of helminthiasis control in district level: the responsible person, the budget, the colaboration with other sectors, the integration of neglected disease control. 4. Understanding the other control method other than mass drugs administration

Method Dr. Bintari Dwihardiani has visited Cambodia on 18th- 25th November 2010, while dr. Elsa Herdiana did the visit on 28th November – 6th December 2010

1. Visit to the provincial health department in Pursat, Batambang, and Siem Reap province, discussion with the MoH staffs who is responsible to vaccination program and communicable disease control program

2. Visit to parasitology laboratorium of National Malaria Center 3. Review the documents from National Malaria Center

Results

General health system Figure 3 organisational chart of ministry of health

In the province, there is provincial health department (PHD), which has the same structure. PHD consists of several operational districts (OD). In each OD there are health centers and one referral hospital. Each OD serves 100,000-200,000 people

Figure 4 The health system of Cambodia

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Ministry of health structure which related to helminthiasis control The national task force for the control of soil transmitted helminthes, schistosomiasis, and for the elimination of lymphatic filariasis was founded to establish and review the national policy for helminthes control and lymphatic filariasis elimination. The group consists of various departments of ministry of health and representatives from Ministry of Education, Youth and Sport, Ministry of Rural Development, Ministry of Water Supply and Meteology, WHO, and UNICEF. In the implementation level, the program is managed by the national program management group for the control of soil transmitted helminthes, schistosomiasis, and the elimination of the lymphatic filariasis. The national program management group consists of national program manager for lymphatic elimination program, national program manager for soil transmitted helminthiases program and schistosomiasis program, school health department from ministry of education youth and sport, national malaria center, WHO technical officer, UNICEF technical officer, program managers from collaborative partners.

Figure 5 Framework of the national program for the control of STH, schistosomiasis, and the elimination program of lymphatic filariasis(5)

In the initial process WHO supported the funding. The program then received funding from JICA, Korean government, and Asian Development Bank.

Implementation of helminthiasis control The helminthiasis control is done through mass drugs administration (MDA) and case management. Mass drugs administration is done in April and September. MDA is done through primary school for the school age children, and in the community. For pre-school age children the MDA is done through outreach activities. Deworming is done also to the pregnant women in the first trimester through antenatal care activity. Outreach activity is done to catch up the population who has not been covered by regular program. The regular programs include:

1. Extended immunization program 2. Vitamin A distribution

Ministry of health National task force

National program management group for the control of soil transmitted helminthes, schistosomiasis, and the elimination of the lymphatic filariasis

Integration with malaria control program and collaborate with other NGOs and other ministries

Provincial health department Operational District Health Systems

Referral hospitals

Health centers

Pagodas Schools Communities

3. Deworming Not all health centers have outreach activity because of limited funding. The deworming programs involved also the ministry of education. In the school system, the coordinators of school cluster collaborate with MoH in operational district and province. The health activities are adapted to the structure of education system. Other than school, the delivery of drugs are supported by UNICEF and WFP Some drugs are supplied by Glaxo Smith Kline and Johnson and Johnson.

The collaboration with other programs was done in the past, for example with the malaria control program. Distribution of impregnated mosquito net was distributed together with Mebendazol in the endemic area in year 1999.

Case management of helminthiasis in the health center is based on clinical and stool macroscopic diagnosis. When the symptoms persist the patient will be asked to go to referral hospital where microscopic examination will be done. National Center for Parasitology, Entomology and Malaria Control has standardized laboratory to conduct helminhiasis diagnosis. Many international groups of scientists or NGO are working in this center in helminthiasis, usually after this center approves their project proposal submitted to this center. Japanese scientists are interested to learn schistosomiasis, Korean in Soil transmitted helminth and Australian in fasciolopsis. Basically what is done in the CNM lab is species identification. This routine examination is always done regularly before or after mass drug administration. For routine diagnosis of soil transmitted helminthiasis, some conventional protocols are used: qualitative (direct/indirect examination such as Faust or Ritchie method) examination and quantitative methods (Kato Katz). For schistosomiasis, besides Kato Katz or formalin detergent technique, seroimmunodiagnosis are often done (Enzyme-linked immunosorbent assay/ELISA). In the low endemic areas, the sensitivity of KatoKatz method is not sufficient then seroimmunodiagnosis indicators could be used for monitoring. ELISA method is very useful fordiagnosis and monitoring at community level. For filariasis, besides blood smear method, serological method (immunochromatographic card test/ICT) is also performed. To help the diagnosis, bench aids for helminthiasis is provided, together with the protocols for stool examination. The bench aids consist of morphology of eggs (colourful atlas) found in the stool and also the comparison of eggs’ sizes.

Challenges The lack of human resources is still a problem like in any other developing countries. The staffs in the structures in the rural area still facing work overload. The problems of health workers retention in the rural province include personal problems and structural problems. The structural problems demotivate the staffs because they work against the provision of high quality services, for example: fragmentation of service delivery and structure, limited capacity and shortage of high qualified health staff, competition with the private sector, and shortage of medical supplies. The personal problems are the appreciation of work responsibilities and position, the personal ability to cope with the financial barriers, opportunities for professional development.(6)

When there was enough funding support from WHO, there was an incentive for the school cluster coordinator and school teacher to distribute the drugs and collect back their reports, regular meeting to identify any obstacles in the fields. However, once the funding is stop, there is no more incentive for school cluster coordinator. As a consequence, it is hard to ask them to report. In the Pursat district, the outreach activity did not work as planned because there is lack of funding and human resource. Cambodia has 24 provinces, and to reach remote areas it definitely needs cost for transportation as some areas are very difficult to reach. The other problem is re-infection. The possibility to get re-infection is high. Although children are treated but because sanitation, environment and water supply and education are not to be developed then they are prone to be re-infected. Schistosomiasis mekongi causes public health problem in Cambodia. The infection results from contact with river water in areas where the infection is endemic, inhabited areas along the Mekong and its tributaries in the Kratie and Stung Treng Provinces. Treatment is praziquantel in 64 villages around the Mekong river. Under strong control pressures (combination of treatment and campaign and information, education and communication) for 7 years, the parasitological indicators are kept at a very low level. However, concerns are risen as 1. Intermediate host population was not affected from the control, 2. Although the stool examination the schistosomiasis prevalence is low, the serological study shows still low prevalence of schistosomiasis, 3. The prevalence of schistosomiasis might be influenced by border country, Lao. When the vector/reservoir host is not treated in Lao, it will be a potential source of infection in Cambodia. After started the Mass Drug Administration of filariasis (DEC) in pilot areas (2004), 50% of endemic implementation (2005) and 100% of endemic implementation (2006), only less than 50 cases of chronic manifestation of filariasis are identified, means that elephantiasis are found without any presence of microfilaria in their blood. The problem now is related with reconstruction of affected areas that need costly surgery. Most cases of elephantiasis are poor people while the health insurance might not sufficient to go through plastic surgery.

Lesson learned In the next table, we try to compare the the conditions of Indonesia and Cambodia, which facilitate or not facilitate the helminthiasis control program. Variabel Cambodia Indonesia Authority system Centralized:

- health officers decided by MoH

- budget for health activities decided by MoH

Decentralized: - health officers in the

district are chosen and paid by the district government

- budget for health

activities decided by the district government

Size of the country Small, centralized system can control the activities

Big

Position of control program under Ministry of health

Integrated parasites control program (malaria, helminthiasis, schistosomiasis, filariasis)

There are separate subdirectorates of filariasis, malaria, schistosomiasis, and helminthiasis. The process to joint helminthiasis and filariasis under the same sub directorate is ongoing.

Collaboration with other sectors

Collaboration with ministry of education to do school deworming is very strong

In health center level, there is a school health program with many health activities in the school. In some province, deworming activity in the school was stopped because of no funding.

The political commitment to control the parasites disease is very strong. WHO gave a strong pressure in the beginning of program and gave the funding. This commitment is supported also by the centralized health system. However, what is implemented in the centralized system in Cambodia, could be done in the district level in Indonesia in the framework of district autonomy. The integrated outreach activities in the health centers are good strategies to catch up the population missed by the program. In the health centers in Maluku Tengah, there is health promotion officer and environmental hygiene officer who do the visit to educate and verify the health practice of the population. The system of integrated outreach in Cambodia can be a good strategy to apply in Indonesia’s districts. This outreach activity can improve to effectiveness of many health programs in the health centers in integrated manner, so it may reduce the cost. We face the same human resource problems as in Cambodia. Interestingly, salary and financial incentives are not always the main factors which made the health workers do not stay in rural area. The incentives we can offer to the health workers may not be in form of money or salary, but also in the form of opportunities to study in the cities, training, or arrangement of day off to see their family. Moreover, improvements of service quality, provision of needy materials, and the excitement of the population to use public health services, are the structural improvements which are necessary to retain and to motivate the health workers.

Reference List

(1) World Health Organisation. Neglected tropical diseases: neglected tropical diseases, hidden successes, emerging opportunities. Geneva: World Health Organisation, 2009.

(2) Croce D, Porazzi E, Foglia E, Restelli U, Sinuon M, Socheat D et al. Cost-effectiveness of a successful schistosomiasis control programme in Cambodia (1995-2006). Acta Trop 2009.

(3) Sinuon M, Tsuyuoka R, Socheat D, Odermatt P, Ohmae H, Matsuda H et al. Control of Schistosoma mekongi in Cambodia: results of eight years of control activities in the two endemic provinces. Trans R Soc Trop Med Hyg 2007; 101(1):34-39.

(4) Subdirectorate of diarrhea haogidCDCdMoHRI. Pelaksanaan Program Cacingan di Daerah Sentinel tahun 2009. 2009.

(5) The National Task Force for the Control of Soil Transmitted Helminthiases

SaftEoLF. National Policy and Guideline for Helminth Control in Cambodia. 2004.

(6) Chhea C, Warren N, Manderson L. Health worker effectiveness and retention in rural Cambodia. Rural Remote Health 2010; 10(3):1391.