Vol. 2, No.

1, April 2011

Editorial note


Volume 2, number 2, December 2011, pages 51-100, ISSN 2087-7021

Health Science Journal of Indonesia

A. Suwandono S. Idaiani

Editorial note Inter-rater reliability of Health of Nations Outcome Scale (HoNOS) among mental health nurses in Aceh HoNOS has a good inter-rater agreement among mental health nurses in Aceh. Cold working room temperature increased moderate/severe qualitative work stressor risk in Air Traffic Controllers A working room temperature that was too cold increased risk of moderate/ severe overload qualitative work stressor among air traffic controllers. Risk factors of post partum haemorrhage in Indonesia Eclampsia is the strongest for post partum haemorrhage. Signs or symptoms of complications in pregnancy and risk of caesarean section: an Indonesia national study Women with any sign or symptom of complications in pregnancy have an increased risk of c-section. Quality of refill drinking water in Greater Jakarta in 2010 Refill drinking water in Greater Jakarta in general has a good quality of the physical and chemical parameters. Fingernail biting increase the risk of soil transmitted helminth (STH) infection in elementary school children Fingernail biting and no hand-washing before meals and no hand washing with soap after defecation increased the risk of soil transmitted helminth infection. Sensitivity and specificity of immunocytochemical assay for detection of Dengue virus 3 infection in mosquito Immunocytochemical assay has a high sensitivity and high specificity to detect DENV-3 infection on mosquito head squash. Virus culture and real-time RT-PCR in influenza-like illness cases in Indonesia 2007-2008 Virus culture was still essential and considerably efficient to support real-time RT-PCR detection in ILI cases in Indonesia. Several dominant clinical symptoms associated with InfluenzaA in Indonesia In addition to fever and coughing, runny nose, sore throat, and ever had fever dominantly associated with influenza A.

51 53

D. Astuti B. Basuki H. Mulijadi R. P. Jekti E. Suarthana Suparmi B. Basuki


66 71

A. A. Kurniatri


L. Sofiana S. Sumarni M. Ipa D. Widiastuti B. Yunianto S. R. Umniyati N. Wijayanti I. L. Indalao V. Setiawaty H. A. Pawestri Subangkit Roselinda N. Fitri






Buang et al.

Health Science Indones

Acknowledgment of Reviewers Volume 2, 2011
Ani Isnawati
Center for Basic Biomedical and Health Technology, Institute for Health Research and Development, Ministry of Health of Indonesia

Joedo Prihartono Retno Gitawati

Faculty of Medicine, Universitas Indonesia, Jakarta Center for Basic Biomedical and Health Technology, Institute for Health Research and Development, Ministry of Health of Indonesia

Bob Tilden

HSJI international advisor

Christine Thayer

Saleha Sungkar

HSJI international advisor, France

Faculty of Medicine, Universitas Indonesia, Jakarta Supratman Sukowati Centre for Technology in Public Health Intervention, National Institute for Health Research and Development, Ministry of Health of Indonesia Suryadi Gunawan Center for Applied Technology and Clinical Epidemiology, National Institute for Health Research and Development, Ministry of Health of Indonesia Tris Eryando Center for Applied Technology and Clinical Epidemiology, National Institute for Health Research and Development, Ministry of Health of Indonesia

Didi Danukusumo

Faculty of Medicine, Universitas Indonesia, Jakarta

Elisabeth Emerson

Former WHO consultant; HSJI international advisor; Minnesota, USA

Eva Suarthana

Faculty of Medicine, Universitas Indonesia, Jakarta


Center for Applied Technology and Clinical Epidemiology, National Institute for Health Research and Development, Ministry of Health of Indonesia


Faculty of Medicine, Universitas Indonesia, Jakarta

Weda Yuwana

Air Traffic Control of Soekarno-Hatta Airport, Jakarta

Health Science Journal of Indonesia
Editor-in-chief: Trihono; Deputy Editor-in-chief: Agus Suwandono; Editorial board: Asri Adisasmita, Atmarita, Betty Rossiehermiati, Herqutanto, Minarma Siagian, Muchtaruddin Mansyur, Ratna Juwita, Sanjaya, Siti Isfandari, Sudarto Ronoatmodjo. International Editorial Advisory Board: Bastaman Basuki (Universitas Indonesia, Indonesia), Christine Thayer (Health for Development, France), Elisabeth Emerson (Minnesota Department of Health, USA), Hans-Joachim Freisleben (German-Indonesian Medical Association, Germany), Martin Weber (WHO Indonesia, Indonesia), Robert Tilden (Consultant, Indonesia) Layout: Jerico Franciscus Pardosi, Muhammad Kamil; General Affairs: Cahyorini, Endang Sri Widyaningsih, Erwin Mustikowati, Leny Wulandari, Siwi Wresniati. Printed by Badan Penerbit Fakultas Kedokteran Universitas Indonesia. Subscription: The journal is published quarterly and should be subscribed for a full year. Advertisement: Only advertisements of health science or related products will be allowed space in this journal. For all inquiries please contact Health Science Journal of Indonesia Editorial Office at Badan Litbangkes, Gedung Pusat Teknologi Intervensi Kesehatan Masyarakat, Jln. Percetakan Negara No. 29 Jakarta Pusat 10560, Indonesia; Tel (62-21) 42872393. Fax (62-21) 42872392. E-mail: healthsciencejournal@yahoo.com

Vol. 2, No. 2, December 2011

Editorial note


Editorial Note
Dissemination of Health Research for Better Health Programs

As stated by the Director of Research Policy & Cooperation, World Health Organization (WHO), Geneva, Dr. Tikki Pangetu et al (2003), knowledge produced by health research, if disseminated widely, is a global public good. Knowledge contributes to the policies, activities, and performance of health systems, and to the improvement of individuals’ and populations’ health. Using existing knowledge adapted to local conditions is particularly crucial in achieving the local, country as well as Millennium Development Goals and other world committment of health development goals. To achieve these and other health-related goals, a well-functioning health system must be able to access and utilize research-based knowledge and the products of research. WHO SEARO Regional Director, Dr Samlee Plianbangchang (2005) said that the vision of knowledge management and sharing/dissemination was to attain global health equity through better knowledge management and sharing/dissemination, was extremely important to health development. The contribution of knowledge management and sharing/dissemination to health for all will be enhanced if the application of this concept was succesfully implemented to empower the people at large to be able to plan and take care of their own health effectively. Another real challenge was to ensure accessibility and utilization of the relevant knowledge in health development processes at all levels. The publication of research findings is considered to be the primary output of the research process. Research can be utilized in two main ways: first, for developing new tools (drugs, vaccines, devices and other applications) to improve health; and second, for translating, communicating, and promoting the utilization of research to inform health policies, strategies, and practices, particularly within health systems. Research can also be used to educate the population and change public opinions and practices. It is generally agreed that a wide gap exists between current health systems and the needs that health systems should address, one major cause being the inability to synthesize existing research outputs and apply existing knowledgetowards improving interventions and the performance of health systems (WHO, 2004, Knowledge for Better Health). One of the major dream of the National Institute of Health Research and Development (NIHRD) is to be a scientific institution which can drive the national health development based on the research evidences found by NIHRD researchers and its networking partners. The Health Science Journal of Indonesia (HSJI) is one of the efforts of NIHRD in knowledge dissemination, to share the research findings conducted by health researchers in NIHRD and other academic and private research institutions. Dissemination of health research through HSJI hopefully can be used to improve the quality and efficiency of health programs and policy formulation, as well as to improve capability of the health researchers in influencing the use of evidence based to advocate the health providers for better health programs. The third edition of HSJI consists of 9 articles covering several diciplines of health knowledge such as mental health nurses in Aceh, quality work stressor risk in air traffic controllers, risk factors of post partum haemorrhage in Indonesia, complications in pregnancy and risk of caesarean section in Indonesia, quality of refill drinking water in Jakarta, fingernail biting and the risk of soil transmitted helminth (STH) infection in elementary school children, immunocytochemical assay for detection of Dengue virus 3 infection in mosquito, and virus culture and to real-time RT-PCR in influenza-like illness cases in Indonesia. Several of them are original research carried out by NIHRD and other health institution researchers while some of them are using data based on the results of National Health Basic Research 2010 or “Riskesdas 2010”.



Health Science Indones

Initially this third and the fourth edition of HSJI were to focus on the special topic of “Riskesdas 2007 and Riskesdas 2010” particularly in some topic related to the achievement efforts of health development programs in Indonesia to the targets of Millenium Development Goals 2015 as well as the analysis of speciment related to non-communicable and communicable diseases based on the specimens taken during the “Riskesdas 2007”, but unfortunately the NIHRD researchers were too busy with the implementation of National Health Facility Research in 2011 (“Rifaskes 2011”) and other health research such as research for Development of Area with Health Problems (“PDBK”), so that the theme was changed to a more general health research focus with some analysis of “Riskesdas 2010”. We are hoping, however, those topics, and some of the “Rifaskes 2011” preliminary results as well as the research of “PDBK” results can be published in the next editions of the HSJI. In the up coming editions, HSJI editors invite all health researchers across Indonesia, particularly those who are coordinated under the National Health Research and Development Network (“Jaringan Penelitian dan Pengembangan Kesehatan” or “Jarlitbangkes”) to publish their research findings in this journal by submitting their scientific articles to HSJI. Thank you very much to all of the national and international editors and reviewers who have worked seriously to publish this HSJI edition. The HSJI also congratulates all of the authors who had their articles published in this third edition and for their successful negotiation with our peer review team members and editors. Our special thanks and best appreciation is forwarded to Professor Bastaman Basuki who has wisely and seriously carried out some necessary writing skill training and assistance to the researchers in NIHRD in developing their articles.

Agus Suwandono Deputy Editor-in-chief Health Science Journal of Indonesia, National Institute of Health Research and Development (NIHRD) Ministry of Health, Republic of Indonesia

Vol. 2, No. 2, December 2011

Inter-rater reliability of HoNOS


Inter-rater reliability of Health of Nations Outcome Scale (HoNOS) among mental health nurses in Aceh
Sri Idaiani
Centre for Applied Health Technology and Clinical Epidemiology, National Institute of Health Research and Development, Indonesia Ministry of Health

Latar belakang: Alat ukur Health of Nations Outcome Scale (HoNOS) dapat digunakan untuk keperluan rutin dan menilai perkembangan status fungsional pasien gangguan jiwa di klinik maupun komunitas. Tujuan penelitian adalah melakukan uji kesepakatan (agreement) bagi perawat jiwa yang akan menggunakan alat ukur ini di Indonesia. Metode: Lima puluh lima orang pasien psikosis yang sedang di rawat di Rumah Sakit Jiwa (RSJ) Provinsi Aceh dinilai secara bergiliran oleh 11 orang perawat jiwa menggunakan alat ukur HoNOS. Penilaian dilakukan pada bulan September 2011. HoNOS terdiri dari 11 pertanyaan. Kesesuaian di antara perawat terhadap masing-masing pertanyaan dinilai menggunakan koefisien intra-class classification correlation (ICC). Hasil: Empat puluh dua persen pasien berusia 31-40 tahun, termuda berusia 24 tahun dan tertua berusia 59 tahun, mayoritas laki-laki, dan 38% mengalami psikosis selama 5-10 tahun. Tiga puluh enam persen perawat berusia >40 tahun sebagai penilai, separuhnya perempuan, dan 55% telah bekerja lebih dari 10 tahun. Nilai ICC untuk masing-masing pertanyaan secara umum baik (berkisar antara 0,8-0,9). Kesepakatan yang baik didapatkan di antara perawat Rumah Sakit Jiwa, perawat Puskesmas, maupun gabungan keduanya. Kesimpulan: HoNOS memiliki inter-rater agreement yang baik dan dapat digunakan pada penelitian dengan setting yang sama. Untuk penggunaan di populasi yang lebih besar dan berasal dari daerah yang berbeda disarankan untuk melakukan uji reliabilitas serta validitas dengan jumlah sampel yang lebih besar. (Health Science Indones 2011;2:53-7) Kata kunci: HoNOS, agreement, psikosis

Background: The Health of Nations Outcome Scale (HoNOS) instrument could be used for routine purposes and assessing the functional status of the mental health patients in clinical and community settings. The objective of this study was to evaluate the agreement of the scale among mental health nurses who would use this tool in Indonesia. Methods: Fifty five psychotic patients who were hospitalized at a mental hospital in Aceh were evaluated by 11 mental health nurses using the HoNOS instrument. The agreement between the nurses on each questionnaire item was evaluated using the intra-class correlation (ICC) coefficient. Results: Forty-two percent of the patients were 31-40 years of age, the youngest was 24 and the oldest was 59, most of them were males, and 38% had psychosis for 5-10 years. Thirty-six percent of the nurses aged >40 years as raters, half of them were females, and 55% had worked for >10 years. ICC values were generally good (ranging from 0.8 to 0.9) among the mental health hospital nurses, as well as the community health centers nurses and a combination of both. Conclusion: This instrument showed a good inter-rater agreement and could be used in future research with the same settings. For a wider use in different regions, it is recommended to test the reliability and the validity of the HoNOS in a larger study population. (Health Science Indones 2011;2:53-7) Key words: HoNOS, agreement, psychosis.

Corresponding author: Sri Idaiani E-mail: sriidaiani@yahoo.com

and New Zealand.54 Idaiani Health Science Indones Assessment of the effectiveness of a mental health intervention requires a measurement tool to assess the improvement of the outcomes of the mental disorders. psychotic and nonpsychotic disorders. especially for patients with mental disorders. Each nurse assessed 1-2 patients using the HONOS based on the information contained in CHC medical records and interviewed patients and their families. the researchers had three sessions to discuss issues related to language. A pilot study was done to evaluate the HoNOS. content. Ten psychotic patients from six CHCs in the city of Banda Aceh and Aceh Besar district were assessed by six mental health nurses from the CHC. 55 patients were assessed by 11 mental health nurses between September 26 and October 4. Germany. which only measures the degree of symptoms alone.3-5 This tool was designed by Wing and colleagues in 1990.2 Functional status assessment emphasizes more on improvement of one’s ability in terms of functioning on a daily basis. was finalized after the group discussion. which .2 The Health of Nations Outcome Scale (HoNOS) is a measuring tool that can assess the development of functional status. at the same time all nurses joined a 3-hour short course about how to use the measuring instrument in the hope they would have the same understanding of the meaning of the questions. and the Global Assessment Functioning (GAF) to measure the patients’ functional status. and the feasibility of this measuring tool. Nurses voluntarily joined the study. Assessments of the results have been published in numerous articles and publications. both schizophrenia. This step was followed by a group discussion panel of researchers from NIHRD who produced a questionnaire measuring tool with content and translation in Bahasa Indonesia. then the most important thing is the ability to function optimally. Italy. Patients in special wards (i. standardization of how to conduct such study. The inter-rater agreement of the Indonesian version of the HoNOS were evaluated among 11 nurses (six nurses who served at CHC in Banda Aceh and Aceh Besar district and five nurses who served at the Province of Aceh Mental Hospital). The guideline was translated from the original. The nurses evaluated 55 psychotic patients who were being treated at the Province of Aceh Mental Hospital. Problems in the assessment of these outcomes include the absence of the following: a clear statement of the purpose of the intervention or treatment.1 However. The flow of the research was described in Figure1.2 GAF was designed as a part of the fifth axis of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Before assessing the patients. If someone has a late disability. and others. It has also been used in Canada. Of 63 eligible patients. clear outcome indicators.3-6 Other measuring tools that have been used in Indonesia are the Positive and Negative Symptoms Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS). Australia. The inclusion criteria includes residing in the city of Banda Aceh or Aceh Besar district and the patient was not expected to be discharged within 2 weeks from study inception. The Indonesian version of HoNOS. in a way that it would at least be understandable by the community health center (CHC) nurses.1 Assessment of the outcome of mental disorders using functional status is better than simply assessing the improvement of clinical symptoms. especially in the United Kingdom. GAF is widely used in clinical settings by psychiatrists to measure the improvement of the patients’ functional status. France and Norway. These findings from a study by Barbach and colleagues was cited by Trauer. the test’s reliability.1. Afterwards. Afterwards. drug user or having physical comorbidity) were also excluded.e. and the appropriate time intervals to assess the improvement.1. especially for the Aceh population.3 The HoNOS can be used for assessing the outcome of the mental disorders and other routine assessments. In the preparation phase. Each rater assessed each patient. they were back translated into English by different translators. 2011. The mental health nurses involved in this study were nurses who run the mental health program at CHC and the selected CHCs have ample mental health patients. Previous studies show that the validity of the content. and the inter-rater reliability were good1. METHODS This study was conducted in Aceh Province because Aceh is the only province in Indonesia that has community mental health programs that have been implemented in all districts and cities. the HoNOS questionnaires were first translated from English into Bahasa Indonesia.3 This tool has been used in many countries.

2.Vol.e. Ministry of Health of the Republic of Indonesia. high = graduate schools) were used. The four dimensions were translated into 12 items of questions. For each item. items 6-8 were in the symptoms domain. For this analysis. Item number 3 (i. while the ethics approval was obtained from the Ethics Committee of the National Institute of Health Research and Development (NIHRD). high = senior high school or graduate schools). However. A value of 9 was assigned when the rater did not know or the condition of the patient did not fit the score criteria. This low number might be explained because of good observation by hospital staff. with the following criteria: 0 = no problem. impairment. Item number 2 of the HoNOS was not included in the analysis because there were only three patients who were reported to have a self harm problem.. Research permission was obtained from the Ministry of Home Affairs. and social symptoms. ICC is a good method to evaluate inter-raters agreement because ICC controls for measurement errors that might occur. Flow of research was developed by Wing and colleagues. December 2011 Inter-rater reliability of HoNOS 55 HoNOS: English version Group discussion Translation and back translation HoNOS: Indonesian version Pilot study: assessment of 10 psychotic patients by 6 nurses at Community Health Centers Reliability test (inter-rater agreement): Assessment of 55 psychotic patients treated at mental health hospital by 6 CHC nurses and 5 hospital nurses Figure 1. Thirty-six percent of the nurses were 40 or more years. items 4-5 were included in the impairment domain. 2 = mild problem 3 = moderate to severe problem. substance use) was .0. Patients were mostly male and more than 80% were between the ages of 24 and 39. Inter rater-reliability analysis was performed by calculating intra-class correlation (ICC) coefficients using a two way mixed model and absolute agreement type. All nurses had attended the basic level of training on community mental health nursing (CMHN). Four nurses had an advanced course on CMHN. The average measure coefficients were reported. and 4 = severe to very severe problem.7 Analysis was done using SPSS version 15. and items 9-12 were in the social domain. for the nurses only two categories (medium = high school. 2. Total scores and sub-total scores for each domain were calculated. the score ranged from 0 to 4. and 55% had tenure of more than 10 years (Table 2). 1 = minor problem that does not interfere with the function. a patient’s education was divided into three categories (low = no school or not completed primary school. The HoNOS consists of four dimensions of behavior. RESULTS The characteristics of 55 patients are presented in Table 1. medium = completed primary school or junior high school. Items 1-3 were the domain of behavior. half of them were female. No.

n = 55 22 23 10 49 6 10 20 25 22 18 6 9 % Age 24-30 years 31-39 years 40-59 years Gender Male Female Education Low Medium High Duration of illness 5-10 years 11-15 years 16-20 years 21-41 years 40. and good Table 2. the hospital nurses.2 36. Table Some because demographic characteristics of the including patients alcohol. Therefore.8 18.5 27.5 54.96 Total (n = 11) 0.8 27.92 0.92 0.3 27. were excluded from the study.85 0. Table 3.5 18. Therefore.5 In general. the ICC were evaluated in three groups: the CHC nurses.4 45.85 0. Intra-class correlation coefficients of HoNOS items No 1 4 5 6 7 8 9 10 11 12 HoNOS items* Agression Cognitive problem Physical illness and disability Hallucination and delusion Depresssion Other symptoms Relationship Activity Daily Living Residential enviroment Day time activity HONOS total score 1-10 items 1-8 items Intra-class correlation coefficients* CHC nurses MH nurses (n = 6) (n = 5) 0.0 10.5 54.4 27.5 10.91 *The original items 2 and 3 were excluded because only 3 subjects had experienced self harm.92 0.92 0.91 0.90 0.3 45.92 0.93 0.0 41.94 0.5 Nurses from the CHC were involved in the pilot assessment of the HoNOS.88 0.94 0.94 0.3 9. the analysis was just for 10 items.2 71.3 27.1 36.89 0. while drug users were excluded from the study.4 45.93 0.97 0.5 37. and all nurses.90 0.84 0.91 0.91 0.56 Idaiani Health Science Indones also not 1.97 0.93 0.81+).91 0.61 0.2 84.93 0.96 0. analyzed patients who used substances.3 36.95 0.94 0.9 31. the inter-rater agreement was good (ICC coefficients ranged from very good (0.3 15.95 0. .93 0. while the hospital nurses were not.3 18. Some demographic and employment characteristics of the nurses (raters) n Age 27-30 year 31-39 year 40-47 year Gender Male Female Education Medium High CMHN course Never Basic Intermediate Advance Period of employment 5-10 year 11-20 year 21-26 year Work sites Mental hospital Community health center 4 3 4 5 6 2 9 3 3 1 4 5 3 3 5 6 % 36.4 45. The first group might know the measurement better than the second group.84 0.82 0.92 0.

M. Mental Health Outcome Measures. Complete evaluation of these aspects should be considered in future studies. Dr.174:380-8. and 50 patients in Geelong showed good reliability. and Dr. DISCUSSION The reliability of the HoNOS among mental health nurses in this study was reliable. and diagnostic criteria of the translated HoNOS were not evaluated. this study only assessed psychotic patients and the nurses who evaluated the subjects were mental health nurses. REFERENCES 1. 2010. 2005.61-0. 2.3. The author would also like to express her sincerest gratitude to Prof. Burgess P. the community mental health program was introduced and further developed in all health centers in Aceh province. Curtis J.9 Acknowledgments The author wishes to thank all subjects who willingly participated in this study. Br J Psychiatry. reliability and interrater reliability. At this moment mental health nurses could be found not only in mental hospitals. Therefore. The subscale structure of the Health of the Nation Outcome Scales (HoNOS. Patients involved in those studies also had a diagnosis of mental disorder. et al. Weir J. Wykes T. Br J Psychiatry. A review of the psychometric properties of the Health of the Nation Outcome Scales (HoNOS) family of measures. Quantifying test-retest reliability using the intra class correlation coefficient and the SEM. Muchtaruddin Mansyur. Sample size can affect the internal consistency. Ommeren V. Trauer T. Trauer T. Charter R. Dr.g.1-5 With these findings. other provinces and not limited to psychotic patients). This might cause bias as the CHC nurses might have a better understanding of the tool. the ICC coefficients between the nurse groups turned out to be comparable. 2000. Wing J.cultural epidemiology. 7. Eva Suarthana. Study samples are too small to produce sufficiently precise reliability coefficients. This study has several limitations. 9. J Strength Cond Res. content. 3 ed. Health of the Nation Outcome Scales Results of the Victorian field trial.34:512-9. 2. while the hospital nurses were not. Hantz P.130:117-29. 4. predictive. Moreover. et al. the reliability of this measurement should be re-evaluated. Bastaman Basuki. Kirk P. Health of the Nation Outcome Scales (Ho NOS) research and development.19(1):231-40. Callaly T. because this study was a small part of a main study assessing the effectiveness of the community mental health program for psychotic patients at CHCs. but also scattered in almost all CHCs in Aceh province. 5. J Ment Health 1999. In early 2005. Validity issues in trans cultural epidemiology. 1998. Preston N. 1999.182:376-8. which varied and was not limited to psychosis.5 The validity. Nevertheless. 100 patients in Nottingham. although they were important aspects in trans. . 6. Br J Psychiatry. the HoNOS could be used in future studies. 3.3. Williamson M. Dodson S. 2003. 2005. 2. Elisabeth Emerson for technical assistance in preparing this final draft. No. editor. London: RC Psych Pub. The Health of the Nation Outcome Scales: validating factorial structure and invariance across two health services. the findings were comparable to much bigger studies in Manchester and Nottingham1. Beevor A.172:11-8. Combs T. December 2011 Inter-rater reliability of HoNOS 57 (0. if the HoNOS is going to be used in other places with different settings (e. Pirkis J. J Gen Psychol.Vol. Global functioning scales. Previous studies in 293 patients in Manchester. In: Thornicoft GT.80). However. This is not the case in other provinces. 8. 2003.8:499-509. Health Qual Life Outcomes [serial on the Internet]. Nurses from CHC were involved in the pilot study. this research was done in Aceh because the province has a good community mental health program that was initiated after the tsunami disaster in 2004.8 Although this study was done in 55 psychosis patients. Aust N Z J Psychiatry. Csipke E.

Indonesia 2 Aviation and Aerospace Health Institute. Faculty of Medicine.67: 95% CI = 0. Results: Subjects were aged 27–55 years.58 Astuti et al. Di samping itu.90). Penelitian menggunakan kuesioner standar survei diagnostik stres dan kuesioner stresor rumah tangga. stresor ketaksaan peran. air traffic controller Corresponding author: Dewi Astuti E-mail: dewi. Methods: This cross-sectional study was conducted in November 2008 at Soekarno-Hatta International Airport. Those who had than did not have moderate/severe role ambiguity stressor had 8. Indonesia Abstrak Latar belakang: Pemandu lalu lintas udara (PLLU) kemungkinan lebih besar terkena stresor kerja kualitatif. In terms of the career development stressor.23: 95% CI = 1. moderate/severe role ambiguity. (Health Science Indones 2011. as well as career development stressor were at increased risk for moderate/severe QLWS. consisted of 112 ATCs who had moderate and 13 (9.67: 95% CI = 0.23: 95% CI = 1.13-38.2-lipat SBKL sedang/berat (ORa = 8.7-fold risk for moderate/ severe QLWS (ORa = 3. This study identified several risk factors related to moderate qualitative work load stressor among the ATCs.6-kali berisiko SBKL sedang/berat (ORa = 6. Kesimpulan: Subjek LLU yang merasa suhu ruangan terlalu dingin. personal responsibility.59].35. mereka yang mempunyai stresor ketaksaan peran sedang/berat berisiko 8. stresor beban kerja kualitatif.85).2 Bastaman Basuki.7-kali risiko SBKL sedang/berat (ORa = 3. (Health Science Indones 2011.2:58-65) Key words: working room temperature.075).2:58-65) Kata kunci: suhu dingin.63: 95% interval kepercayaan (CI) = 1.6-fold risk for moderate/severe QLWS (ORa = 6.6%) ATCs who had slight QLWS. those who had it than did not have it had a 3.64: 95% CI = 1.90). Subjects consisted of active ATCs with a minimum of six months total working tenure. mereka yang mempunyai stresor tanggung jawab sedang/berat mendapatkan dibandingkan dengan tanpa stesor ini 6. Tujuan penelitian untuk mengidentifikasi beberapa faktor yang berkaitan dengan stresor kerja kualitatif moderat (SBKL) sedang di antara PLLU di Bandar Udara Internasional Soekarno-Hatta.13-38.88-15.2-fold risk of moderate/ severe QLWS (ORa = 8.1.79-65. Those who felt than did not feel the working room temperature was not too cold had 11fold moderate/severe QLWS [adjusted odds ratio (ORa) = 10. Ministry of Transportation.astuti@rocketmail.79-65.85).com . Kuesioner diisi oleh subjek. P = 0. Health Science Indones Cold working room temperature increased moderate/severe qualitative work stressor risk in Air Traffic Controllers Dewi Astuti.1 Herman Mulijadi3 1 2 Department of Community Medicine. Universitas Indonesia Indonesian Civil Aviation Institute. Hasil: Subjek berumur 27-55 tahun terdiri dari 122 PLLU dengan SBKL sedang/berat dan serta 13 (9.13-59. Model menunjukkan bahwa mereka yang merasa dibandingkan dengan yang tidak merasa suhu ruangan terlalu dingin mempunyai 11-lipat risiko SBKL sedang/berat [rasio odds suaian (ORa) = 10. tanggung jawab personal dan pengembangan karir sedang/berat mengalami peningkatan risiko SBKL sedang/berat.13-59. Selanjutntya mereka yang mempunyai dibandingkan dengan yang tanpa stresor pengembangan karir sedang/berat mempunyai 3.88-15.35.63: 95% confidence interval (CI) = 1. Those who had than did not have moderate/severe personal responsibility stressor had 6. All questionnaires were filled in by the participants. Conclusion: Those who felt the room temperature was too cold. pemandu lalu lintas udara Abstract Back ground: Air traffic controllers (ATCs) have a high level of responsibility which may lead to qualitative work load stressor (QLWS). The study used standard diagnostic as well as home stressor questionnaire surveys.075). Dibandingkan dengan subjek tanpa stresor ketaksaan peran.59].6%) PLLU dengan SBKL rendah.64: 95% CI = 1. Metode: Studi potong lintang dilakukan pada bulan November 2008 dengan subjek PLLU aktif bekerja minimal 6 bulan. qualitative work stressor. P = 0.

working unit. ambiguity. more than the standard maximum for near misses of 3 miss per year. and decreased situational awareness.2 Air Traffic Controllers (ATCs) are required to work at optimal levels according to international standards. One was the lowest and 7 were the highest score. Subjects were given information by researchers and filled in special questionnaires in their office or at home. and inadequate training or experience to accomplish my job. I only had minimal opportunity to . role conflict and quantitative workload stressors). marital status. My responsibility was primarily about taking care of people rather than things. quantitative workload. The report also found positive correlation between work stressors and performance. experience in problem.Vol. career development.[6] This study aimed to identify work environment stressors and other risk factors related to the moderate qualitative workload among the ATCs. and personal responsibility. slower reaction time. working chair. each sub-group of stressors consisted of 5 questions and every question had a score from 1 to 7. I did not clearly know to whom and who to report. and there is intolerance for any error or mistake in order to guarantee perfect air traffic operation.4. and I did not understand my job role in the organization Personal responsibility was being responsible for customers’ safety. No. each stressor group was divided into 3 categories (low = 1-10. over promotion and low promotion. I did not have authority in doing my obligations. and other complaints. length of employment. Moreover. the medium-heavy qualitative work load stressors would increase operational error errors or mistakes. It consisted of: job standard demands that were too high. It consisted of: I didn’t have enough opportunities to advance in this organization. The total score for each stressor ranged from 5 through 35. I have to find another job in another unit. Subjects consisted of active ATCs at SoekarnoHatta International Airport who had a minimum of six months total working tenure. December 2011 Air traffic controller and qualitative stressor 59 Stressors and stress are main issues affecting the human factor in aviation.3 It was believed the ATCs had excessive workload demands and a high level of responsibility.7 Working stressor questionnaires consisted of role conflict. gender. Work stressors were determined by a diagnostic survey questionnaire which consisted of 6 stressor groups (quantitative workload. I did not clearly understand what my goals are. Career development was potential stress aroused because of work uncertainty. The effect of stress could produce psychological and physical reactions such as fear. They also were at risk for experiencing work stress generated by their working environment or home stresses. anxiety. severe = 24-35). Furthermore. and I was responsible for my colleagues’ careers/ futures. crowded working room. career development. configuration of the room. METHODS This cross-sectional study was conducted in November 2008. smoking habits and sports. education. Moderatesevere qualitative work load stressors would produce stress that would decrease performance. Hence. Stressor questionnaires used standard diagnostics for identifying stress. More details are as follows: Qualitative workload stressor was work variability that required technical and intellectual ability above a worker’s abilities.1. tasks that became more complex day to day. Work characteristics questionnaires included information on job title. I acted or made decisions that affected the safety and welfare of others. noise. and second job/additional job. Role ambiguity was the worker’s feeling that he/she does not have enough information to do the job or does not understand the job sufficiently to fulfill the expectations of the role. Demographic and behavioral factors questionnaires identified age. stress management training. moderate = 11-23. assigned tasks that were sometimes too difficult/complicated. loss of motivation. number of children. Stressors are the source of stresses. I was responsible to guide and/or help my colleagues with their problems. It consisted of: my tasks and job description were not well defined. organization’s expectations that exceeded my abilities and skills. my career will suffer if I stay in this organization. Working environment stressor questionnaires included information on lighting in the room.5 A previous report noted that there were 11 near misses at the Soekarno-Hatta International Airport in 2006. 2. frustration. if I want to advance my position. personal responsibility. qualitative workload. role ambiguity. 2. It consisted of: I was responsible for the development of other employees. decreased attention.

.9 Out of 171 ATCs. working room space. those who had 6-10 years of work experiences were less likely had lower risk to be moderate/severe QLWS than those with 11-30 years. The question was ”if you were at home. The question consisted of: neighborhood noise. and configuration of the working room. moderate = 3-5. To determine a score for role in the home subjects were asked ”what is your role in your home: as the main source of family income. home tension and privacy. leaking and/or damage to part of one’s house. and privacy. length of employment (11-23 years).8 Home stressors included household conditions that might increase or create stress. as a financial support to other family members. Table 2 shows that subjects with slight and moderate/ severe QLWS were equally distributed in terms of job title. as a household repairman. physical home stressor. home tension. Home tension was the responder’s perception of their current home environment. number of children. These were categorized into four groups consisting of role in home. Physical home stressor was a physical or home environment that could create stress. Each role identified was given the score of one. Formal line of command was not obeyed. RESULTS Table 1 shows that most of the subjects had moderate/ severe QLWS were male. I was responsible for all kinds of jobs at the same time and almost uncontrollable. working unit.60 Astuti et al. experience with accident control. those who were not yet married were less likely had a lower risk of having moderate/severe QLWS. as a husband/wife. age group. severe = the tension is very high). and aged between 27-55 years. as a father/mother. Each physical home stressor identified was given a score of one. Sports habit was physical exercise to maintain responder health and was divided into three categories (light such as walking 2-4 km/hour. and (severe = rare). It consisted of: I had to bring my work home every noon or weekend to stay on schedule. 135 (78%) participated this study. and I feel stuck in my career. small house. The total score was determined by adding roles and categories (low = less than 2. but it was still tolerable. Health Science Indones develop and learn new knowledge and skill in this organization. and stress management training. Privacy was time for personal matters without interference from others. For this analysis we excluded 19 subjects who had severe qualitative work stressors. noise. heavy such as jogging 6-9 km/hour). and I felt that I didn’t have periodic time to rest. Table 3 shows that subjects who had slight and moderate/severe QLWS were similarly distributed with respect to working room lighting. noise. moderate = seldom. severe =6-7. The total score was determined by adding all items identified. severe =4-5). I was doing work that was not being done by colleagues and was their responsibility. moderate such as biking 16-20 km/hour. moderate = 2-3. Data analysis used Cox regression 10 using Stata version 9. However. Quantitative Workload Stressor related to limited time. working chair. I was caught between my supervisor and my staff. However. I really had more tasks then could be accomplished in one day. working chair. Working room lighting. as a gardener. and sport habit. how often would you have time for yourself relaxing and enjoying an activity (low = always. working room space and configuration of one’s work station were categorized based on the subjects’ perceptions: The Home Stress Checklist questionnaire included one’s role in the family. I received contradictory orders from one or more person(s). Table 1 shows that subjects who had slight and moderate/severe QLWS were equally distributed with respect to gender. The resulting score placed the subject into one of three categories (low = less than 1. home physical factors. dense neighborhood. as a payer. flooded neighborhood. messy house. It consisted of: I was doing unnecessary tasks. Role conflict was conflict that was `created because of a mismatch between role demands and personal needs. The results placed the subject into one of three categories (low = small dispute and can be resolved. In addition. moderate = several tensions. unsafe neighborhood. as a home decorator. I spent too much time at unnecessary meetings and wasted my time.

00 0.00 0. habits characteristics and risk of moderate qualitative work load stressor Qualitative work load stressor Slight (n=13) n Gender Male Female Age 21-29 years 30-39 years 40-49 years 50-55 years Marital status Married Not yet married Divorce/widow(-er) Number of children None 1-2 children 3-4 children Sport habit None Mild Moderate/ Heavy Smoking habits Never Ever Current 12 1 1 8 2 2 11 2 0 3 6 4 3 8 2 0 4 6 3 Moderate/severe (n=122) n 113 9 10 59 37 16 117 3 2 15 78 29 31 68 22 1 65 30 27 Crude odds ratio 95% confidence interval P 1.96 1. No.08-6. Those who had than did not have moderate/severe role ambiguity stressor had 8.33 Reference 0.60 1.31 0.00 0.63].93 0.67.00 0.55 Reference 0.784 0.11-11.785 0.459 n/a=not applicable .82 1.11-2. Subjects who felt than did not feel the working room temperature was not too cold had 11-fold moderate/ severe QLWS [adjusted odds ratio (ORa) = 10.7-fold risk for moderate/severe QLWS (ORa = 3.14 n/a 1.64 0. However.23).209 0.08-1.043 Reference 0.73 1.09-10.00 0.084 0.64). December 2011 Air traffic controller and qualitative stressor 61 Table 4 shows that subjects with slight and moderate/ severe QLWS were similarly distributed with respect to family role.45 1. those who had moderate than low physical home stressors were at a greater risk for moderate/severe QLWS than those with low physical home stressors.653 0. 2. Table 1. home tension and privacy.82 Reference 0.58-11.7.2-fold risk of moderate/severe QLWS (ORa = 8.64 0. Some demographic.Vol.863 0.02-0.17 0.20-3.21-0. In terms of the career development stressor. Those who had than did not have moderate/severe personal responsibility stressor had 6.15-22.6-fold risk for moderate/severe QLWS (ORa = 6.948 1.06 Reference 8.53 0.85 0.55 0.65 0. those who had it than did not have it had a 3.075).630 0.80 1.967 0.00 2.28. P = 0.30 0. 2.01 Reference 0.

00 1.31 1.924 .215 12 1 99 23 1.34-3. Health Science Indones Table 2.56 1.34-22.48 Reference 0.33 0.33 1.27-19.59 Reference 0. Some environment work characteristics and risk of moderate qualitative work load stressor Qualitative work load stressor Slight Moderate/severe (n=13) (n=122) Working room lighting Bright Dim Noise Normal Noisy Working chair Comfortable Uncomfortable Working room space Not crowded Crowded Work station Comfortable Uncomfortable 9 4 62 60 1.623 8 5 0 1 12 58 59 5 35 87 1.62 Astuti et al.26 0.576 Crude odds ratio 95% confidence interval P 0.00 0.137 Table 3.626 0.00 1.65 0.10 0.05-1.804 Crude odds ratio 95% confidence interval P 0.50-5.63 n/a 1.06 Reference 0.72 1.33-7.00 1.18 Reference 0.10 0.79 Reference 0.13 0.066 0.562 0.00 0.00 1.666 12 1 7 6 110 12 64 58 1.02-1.25 0.25-10.24 1.45 0.42-4.00 1.00 2.00 2.54 0.16-10.96 Reference 0.78 Reference 0.19 Reference 0.336 6 7 64 58 1.64-7.00 0.25-2.416 Reference 0.21 Reference 0. Several work characteristics and risk of moderate qualitative work load stressor Qualitative work load stressor Slight Moderate/severe (n=13) (n=122) Job title Operator Supervisor Working unit Air control service Aerodrome control/approach Total length of employment 0-5 years 6-10 years 11-15 years 16-30 years Experience controlling control near miss accident Never Near miss Accident Stress management training Ever Never n/a=not applicable 11 2 7 6 3 6 2 2 95 27 57 65 33 16 38 35 1.

33 P 0.036 1 2 48 6 1. 2.13-59.13-38. 2.037 3 10 9 113 1.28-4.00 6.00 3.23-3.00 0.13 2.79 0.872 0.26-21.00 1.010 Adjusted odds ratio 95% confidence interval P *Adjusted each others for risk factors listed on this Table.010 0.Vol.88-15.10 n/a 1. .849 0.551 0.53 0.26 0.00 8.891 Reference 0.03 1.65 n/a 1.00 1.64 Reference 1.44 Table 5.00 10. The relationship among working room temperature and some of stressors and risk of qualitative work load stressor Qualitative work load stressor Slight Moderate/severe (n=13) (n=122) Working room temperature Cold Too cold Role ambiguity stressor Low Moderate/severe Personal responsibility stressor Low Moderate/severe Career development stressor Low Moderate/severe 5 8 20 102 1.075 2 11 6 116 1.77 0. December 2011 Air traffic controller and qualitative stressor 63 Table 4.00 3.85 0. Several home stressors and risk of slight and moderate qualitative work load stressor Qualitative work load stressor Slight Moderate/severe (n=13) (n=122) Family role Low Moderate Severe Physical home stressor Low Moderate Severe Home tension Low Moderate Severe Personal privacy Always Seldom Rare n/a=not applicable 3 9 1 12 1 0 10 3 0 5 7 1 28 75 19 92 28 2 91 30 1 40 63 19 Crude odds ratio 1.67 Reference 0.223 Reference 0.33-3.79-65.07 Reference 0.23 Reference 1.35 0.59 0.20-21.89 2.90 0.38 95% confidence interval Reference 0.63 Reference 1.45-29. No.

[Cited 2008 Oktober 22].id Top 10 Most stressful jobs. Human Factors Digest No. they shared the responsibility for passenger safety within the group and with other sectors. ICAO Circular.161) Of 135 subjects. The reason was ATCs with low role ambiguity stressor had better self confidence in doing their job with the slight qualitative work load. Montreal. this condition needs to be managed to control the side effects of cold temperature.032) increased risk of the slight qualitative work load stressor compared to the moderate-high role ambiguity stressor.11 and newspaper worker study.12 Since ATCs had specific professional jobs and a slim organizational structure they understood that their career development was limited. 5. [Cited 2008 2. Available from http://www.cdc.64 Astuti et al. [Cited 2008 October 20].9%) were married. 2 divorced and the others (94. the answers were based on subjects’ perceptions.59 (p 0. NIOSH. 8.0%) was lower than reported in the Police study.gov/ulcer/myth. 3. In conclusion.6%). The temperature of the working rooms was relatively low. Special gratitude’s for ATCs who were cooperatively participated in this study. Our model shows that subjects with the perception that the room temperature was uncomfortable had a 22-fold increased risk for moderate qualitative workload. a too cold room temperature and other moderate/severe stressors increased the risk of moderate qualitative workload stressor for ATCs.5%) was lower than that in the Police study (13.htm Costa G. Our study shows that compared to married subjects. competency and responsibility of ATCs to obey standard operation procedures. 1993 p.2%). economical problems in the family that married ATCs might have and which could result an increased qualitative workload stressor.1%).12 Low role ambiguity among the ATCs is caused by duty. Prevalence of the low personal responsibility (6. ICAO. We also thank Dr. Available from http://www. 5 (5. Result showed the subjects with low development career stressor had a 2. ATCs were supported with high technology equipment such as telecommunication. warmer jackets could be provided.11 and with the newspaper worker study (39.12 Low role ambiguity among the ATCs (63.2%). Available from www. reporting system.gov/niosh/topics/stres/ General Directorate of Air Traffic of Indonesia. Most of the non-respondent subjects were on leave or training. . Health Science Indones DISCUSSION This study has some limitations such as limited subjects and a relatively high number of non-respondents among eligible subjects. 33-4. For example. Stress at work. The working room temperature in the radar controller room was 18º–19º C.3%).1%) were unmarried. Career development stressor of ATCs (18. radar etc that would reduce workload difficulties. Hence.4 times increased risk for slight qualitative work load stressor. Our final model revealed that subjects with low versus moderate-high personal responsibility stressor had a 6.12 Since the ATCs worked as a team.cdc. Occupational stress and stress prevention in air traffic control: Literature review. and in the tower room the temperature was 20ºC.11 or with the newspaper worker study (29.go. Acknowledgments We thank to Chief of Air Traffic Service Management to allow us to conduct this study.11 or newspaper worker study(31. Though we explained as clearly as possible the questionnaire. This cold working room temperature was not for personnel but to preserve equipment. unmarried subjects had a 78% lower risk for a slight qualitative workload stressor. This result was similar with an earlier study that found a relation between personal responsibilities and work stressor among the newspaper workers. REFERENCES 1. The model also showed subjects with low role ambiguity had a 10. This might be due to ATCs who felt low personal responsibility would feel the load of qualitative work was also low. Elisabeth Emerson for reviewing the final draft and her excellent suggestions. ATCs with slight qualitative work load (10.12 Even with responsibility for an increased frequency of airplane flights.4%) had a value lower than that in the Police Brigade study (13. [Cited 2008 Mei 14].2%). 4. Human factors in air traffic control.dephub.7 increased risk of slight qualitative work load compared to the mediumhigh career development stressor (P=0. This might be due to household problems over duty. Air trafic services.7%) was higher than that in the Police Brigade study (44.

biomedcentral.html Widyahening IS. 2. Instrument survey study on stress and stress strain diagnosis. Work stress and mental health trend of mental emotional in news paper editors in Jakarta [thesis]. 8. 2006. 13. 7. Faculty of Medicine of Universitas Indonesia. 6:365-82 [Cited 2008 Oktober 20]. Available from http// www. California: Wadsworth Publishing Company. Field study guidance. 2003. 2003. No. Hirakata VN. 1984. The Faculty. Univ Indonesia. Sena A. 14. Jakarta. Isfandari S. 2006. Tangerang. 6. High level of work Stressors increase the risk of mental-emotional disturbances among airline pilots. Available from http://www.pdf. Alternative for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimates the prevalence ratio. Working and health conditions of Italian air traffic controllers. Kanam R. 1992. 2. Med J Indones 2008.org/public/ english/protection/condtrav/pdf/wc-gc-95. Qualitative work overload and other risk factors related to hypertension risk among the Police Mobile Brigade (Brimob). Oct.ciop. . 16:117-21. Kaplan PS. Costa G. 10. 17:188-196. Work environment and stress management in air traffic controllers at Soekarno-Hatta airport [thesis]. [Cited 2008 October 20].Vol. December 2011 Air traffic controller and qualitative stressor 65 October 22]. Med J Indones 2007. Available from www. Barros AJD. Psychology of adjustment. Int J Occupy Safety Ergonomic. Jakarta: National Institute of Health Research & Development. BMC Med Research Method. 12. Setiawan ZY.3. Jakarta. 2001. 11. 9. Stein J.com/1471-2288/3/21. Indonesia Aviation College.pl/807.ilo.

Ministry of Health Republic Indonesia 2 Department of Community Medicine. serta paritas yang tinggi juga meningkatkan risiko PPH. and economic level). wanita dengan kehamilan prematur berisiko PPH 82% lebih tinggi (95% CI = 1.31).2:66-70) Key words: post-partum haemorrhage. Post-partum haemorrhage related to demographic (education level. Metode: Analisis menggunakan sebagian data dari studi potong lintang Riset Kesehatan Dasar (Riskedas) 2010.66 Jekti and Suarthana Health Science Indones Risk factors of post partum haemorrhage in Indonesia Rabea Pangerti Jekti. Placenta previa. National Institute of Health Research and Development. placenta previa meningkatkan risiko PPH 2.49).24@gmail. eclampsia Corresponding author: Rabea Pangerti Jekti E-mail: yekti.69). For this analysis. 1. premature or post-term pregnancies. the subjects consisted of married women aged 13-49 years. those who had than did not uterine rupture had 65% increase PPH (95% CI) = 1.83). Results: This analysis noted 601 subjects had PPH and 19.69-2.69).29-3.57).583 subjects did not have PPH.31). khususnya riwayat antenatal. and high parity.33–2. Hasil: Pada analisis ini terdpat 601 subjek yang mengalami PPH dan 19. (Health Science Indones 2011.29–3. The PPH was defined as bleeding more than two wet pieces materials. Dibandingkan kehamilan aterm. Eklamsia meningkatkan risiko PPH 3.1 Eva Suarthana2 Centre for Biomedical and Applied Health Technology.2-fold PPH (95% CI) = 2. ketuban pecah dini meningkatkan risiko PPH 2. (Health Science Indones 2011.1 kali (95% CI = 1. natal.5 m) selama proses persalinan. Those who had than did not have eclampsia had 3.2 kali (95% CI = 1.5 m each. 2005 and August 2010. kehamilan prematur atau post-term.53–4.yekti.46). sedangkan yang dengan kehamilan post-term berisiko PPH 72% lebih tinggi (95% CI = 1.69]. Dibandingkan wanita dengan paritas 1-2. Faculty of Medicine. Perdarahan post-partum berdasarkan konfirmasi petugas kesehatan tentang telah terjadinya perdarahan dua atau lebih kain (masing-masing 1. Kesimpulan: Eklampsia merupakan faktor risiko PPH terkuat. who had a probability of PPH history. Studi ini mengevaluasi beberapa faktor risiko PPH.5-fold PPH [95% confidence interval (CI) = 2. Subjek yang dipakai unuk analisis ini ialah wanita yang menikah berumur 13-49 tahun dan melahirkan anak terakhir antara 1 Januari 2005 sampai 31 Juli 2010. Compared to women with 1-2 parity.53–4.5 kali (95% interval kepercayaan (CI) = 2. This analysis aimed to evaluate several risk factors of PPH. eklampsia Abstract Background: Post-partum haemorrhage (PPH) is one of the classic triad of causes of maternal death. Universitas Indonesia 1 Abstrak Latar belakang: Perdarahan post-partum (PPH) merupakan salah satu trias klasik penyebab kematian ibu. Methods: This analysis using a cross-sectional Basic Health Research (Riskesdas) 2010 data.com . In term of uterine rupture. gynecologic (parity) as well as obstetric factors. Conclusion: Eclampsia was the strongest risk factor of PPH.16–2.1-fold PPH (95% CI) =1. women with 3-5 and 5 or more parity had an increased PPH risk for 24% and 81% respectively. during giving birth. risiko PPH pada wanita yang berparitas 3-5 dan 6 atau lebih berturut-turut adalah 24% dan 81% lebih tinggi.11–2.53–4.2:66-70) Kata kunci: perdarahan postpartum. dan post-natal. who gave birth of their last child between January 1. ketuban pecah dini.583 subjek tidak mengalami PPH. Other risk factors of PPH include premature rupture of the membranes. placenta previa. Those who had than did not have placenta previa had 2. Those who had than did not have premature rupture of the membranes had 2.

access to drinking water sources. starvation).g. iron tablet consumption during pregnancy.g. Independent variables consisted of demographic characteristics (living in urban or rural area. who had a probability of PPH history. except for employment status (i. eclampsia or eclampsia (characterized by leg swelling. cities. natal and postnatal history characteristics include age at last birth (age of the subject during the last delivery). No.000 live births in 2007. knowledge about pregnancy (danger signs of pregnancy and childbirth). Laboratory tests for diagnosis of malaria and tuberculosis was performed in the field at the referred public health centers (blood sample for malaria testing and sputum for tuberculosis testing). or provinces in Indonesia.000 maternal deaths per year. changes in health problems.583 subjects with negative PPH history. Riskesdas was approved by the ethical committee of the National Institute of Health Research and Development of the Ministry of Health of the Republic Indonesia. decrease morbidity). lower child mortality and improved maternal health). The presence of complications during pregnancies and childbirth was confirmed by the health workers.3 The Indonesian Demographic and Health Survey (IDHS) in 2007 indicated that the MMR in Indonesia was the highest in Asia (228 per 100.5 m each. government employee/ METHODS This analysis used a cross-sectional study Basic Health Research (Riskesdas) 2010 data. placenta previa (the birth canal was blocked by the placenta). the main causes of maternal mortality (more than 90%) in Indonesia are the triad classic. maternal mortality rates (MMR) are still higher than 100 women per 100. student. the subjects consisted of married women aged 13-49 years. as well as safety and basic sanitation facilities.4 According to the Ministry of Health Report in 1998.. namely haemorrhage (40%-60%). The study consists of 601 subjects with positive PPH history and 19. 2. Independent variables were generally dichotomized. caesarian-section or non-vaginal delivery. marital status. In Riskesdas 2010. who gave birth of their last child between January 1. the premature rupture of the amniotic sac (amniotic discharge six hours or more before the child was born). maternal and child health status (e.000 live births.000 live births).g. it is also a .1 The World Health Organization’s statistics suggest that 25% of the maternal deaths are due to PPH. Riskesdas 2010 was expected to provide evidence-based data about post partum haemorrhage (PPH). as well as the progress of health development efforts at the national and provincial level in a three-year period.. and too late to get help by the health provider. 2. during giving birth. employment status. 1. and/or seizures). The causes of the classic triad are known as the “three late”: too late to recognize the danger signs of the pregnancy. Riskesdas data could better describe the health profile of the districts.. Riskesdas sampling followed the National Health Survey (SUSENAS) sampling frame. This analysis aimed to evaluated several risk factors PPH mean to evaluate the development of several health status of the Indonesian people. In addition. educational level. Data was collected through interviews and measurements. December 2011 Eclampsia and post partum haemorrhage 67 In developing countries. and economic status). toxemia gravidarum (20%-30%) and infection (20%-30%). housewife. The National MediumTerm Development Plans (RPJMN) in 2005-2009 targeted a reduction of MMR from 390 in 1990 to 228 per 100.2 It was estimated that there were 140. accounting for more than 100.000 maternal deaths per year or 1 woman died every 4 minutes. uterine rupture (the incidence of uterine tear during childbirth). birth spacing (interval between the last and the previous child). Some indicators that were collected include nutritional status of children (e. 2005 and August 2010. parity (the number of born children). PPH was defined as bleeding more than two wet pieces materials.Vol. hypertension. too late to refer the mother to a referral center. the prevalence of malaria and tuberculosis (e. With a larger number of samples than the National Health Survey. Therefore. Riskesdas 2010 provides specific information on the health Millenium Development Goals (MDG) according to the commitment of global health efforts at national level. Antenatal. age of the subject in 2010. For this analysis. This rate was about 3-6-time higher than MMRs in South East Asian countries and more than 50 times MMR in developed countries.e. One aspect observed in Riskesdas 2010 was the health of the pregnant women.5 The National Institute of Health Research and Development conducted the Basic Health Research (Riset Kesehatan Nasional or Riskesdas) in 2010.

0 75.68 Jekti and Suarthana Health Science Indones army/police.00 0.16 1.3 16. government/army/police employment.7 26. Univariable association between some demographic characteristics and post partum haemorrhage Post partum haemorrhage No Yes (n=18.00 1. 3-5 children.361 1. and term of pregnancy (preterm.0 99.04 1.00 0.651 504 13.1%) did have PPH.009 0.5 0.5 0.179 `8. gynecologic (parity) as well as obstetric eclampsia. low–lowest economic level had higher risk experiencing PPH compared to respective references.67–1..68–1.00 0. Our final model reveals (Table 2) that PPH related to demographic (education level.586 0. student Government. and 35-49 years).8 46.88 1. and premature or post-term birth] factors.08 1.556 0.726 1. uterine rupture.15 1.2 307 294 15 412 174 598 3 186 395 20 308 98 127 68 303 298 37 455 109 552 49 51.3 50.363 5.98 1.e.1 51.7 3.8 8.75 0.905 (96.00 1.0.097 0.17–3.8 17.331 14.328 3.5 36.93–1.935 0. placenta previa.2 7.2 P Crude odds ratio 95% Confidence interval 1. those who had higher education.711 subjects.82 1.1 2.583 396 9.328 0. aterm.92 1.e.9 2.44 Reference 1.35 1. Table 1.00 1.15 1.00 0.481 1. RESULTS Total number of Riskesdas 2010 samples was 91.1 48.08 Reference 0.3 2.806 99 6.4 53.78–1.00 0.98 Reference 0.76 1.895 0.905) (n=601) n % n % Residence Urban Rural Age 13–19 years 20–34 years 35–49 years Marital status Married Single parent Education level None Primary–Junior high school Senior high school – above Employment status Housewife.506 women who had a probability of having post partum haemorrhage.4 10.5 31. post-term).00 0. employment status. and economic level).246 17. labor/ farmer/ fishermen. Table 1 reveals that those who had and who did have PPH similarly distributed with respect of residence.83 – 1.2 91. Independent variables with a statistical significance of p <0.65–1.201 0.6 61.61 0.27 1.1-2 children.990 . parity (i. while 601 (3. > 5 children or grand multipara).1 11. marital status.14 1. Of 19.00 1.768 3.304 0.7 18. and birth spacing.1 91.74-1.973 10.683 3.087 0.5 29.0 65. age during the last gestation (i.4 49.038 18.25 were included in the multiple regression analysis.61–1.8 8.05.544 48.83–1.3 21. farmer.7 70. age birth.9 51.03 0.008 0.5 68. On the sides.02 Reference 0.443 0.51 1.81 – 1.9%) did not have PPH.2 20. 20-34.6 6.42 Reference 0. and others).254 9.6 99. 18. army.06–1. 13-19 years.382 were married.99 Reference 0.20 1.2 75.98–1.926 11. of which 59.3 51. Analysis was done using logistic regression in Stata 9. police Labor. premature rupture of the membranes.0 18.34 0.42 0. fishermen Others Economic level Middle–upper Low–lowest Age birth 13–19 years 20-34 years 35–49 years Birth spacing ≥ 24 months ≤ 23 months 9. Backward stepwise selection was applied to obtain the final model with a statistical significance level of p <0.

which may also cause recall-bias. which could cause selection bias.00 Yes 1. placenta previa or low lying placenta.001 Reference 1.021 0.1 3. pre-term as well as postterm birth increased PPH risk.1 2. Those who had than did not have eclampsia had 3.46 Reference 1. and gestational age < 32 weeks.9 364 60.72 *Adjusted each other among risk factors listed on this Table.014 0. transverse lie.8 1.002 0.033 5.23–2. Those who had than did not have premature rupture of the membranes had 2.1 61 10.Vol.2fold experiencing PPH.506 29.65 Parity 1–2 children 12.49 1. December 2011 Eclampsia and post partum haemorrhage 69 Table 2. and previous postpartum haemorrhage.00 3–5 children 5.31 Reference 1.2 2.0 1.or post-term pregnancy. The operational definition of the study variables.649 66.6 525 87. marginal umbilical cord insertion in the placenta. maternal soft-tissue trauma. Those who had than did not have placenta previa had 2.001 0.82 Post-term 473 2.905) (n=601) n % n % Adjusted odds ratio* 95% Confidence interval Reference 2.57 0.1 566 94.9 576 95. Nevertheless. in this study we found that multiparity. education level.81 Birth term Aterm 17.3 1.48 1. Riskesdas data were based on recall.002 0. prolonged labor. especially in reproductive health.506 97.5 510 84.69–2.001 0. premature rupture of the membranes.1 198 32. those who had than did not uterine rupture had 65% increase of experiencing PPH. Relationship between several gynecologic and obstetric characteristics and post partum haemorrhage Post partum haemorrhage No Yes (n=18.5 91 15.8 1.9 540 89.9 48 8.9 1. A review by Jouppila stated that most PPH cases are caused by uterine atony.16–2. It has rich data for evaluating the MDGs.1-fold experiencing PPH.008 The strongest obstetric factor was eclampsia.11–2. and eclampsia were risk factors of PPH.6 1. We also found that uterine .00 Yes 399 2.0 39 6.9 1. more parities.5 1. DISCUSSION This study shows that pre.47 Reference 1. including eclampsia. a birth weight of more than 4000g.00 Preterm 734 3.5-fold experiencing of PPH. In term of uterine rupture.03-1. eclampsia. Riskesdas 2010 data is the largest community-based study in Indonesia.83 Reference 1.872 94.25 6 or more children 750 4. eclampsia.7 1.7 In concordance. 2. and economic level 0.698 93. were not well defined as in hospital-based studies. obesity of mother. Second. placenta previa.705 98. multiple pregnancy.29–3. and obstetric coagulopathy.6 A twenty-year cohort study (1978-1997) by Kramer and colleagues demonstrated that major independent risk factors for PPH included prior Caesarean section. premature rupture of the membranes and placenta previa were strong risk factors of PPH (OR > 2).07 Uterine rupture No 18.5 28 4.53–4.00 Yes 357 1. uterine or cervical trauma at delivery.1 25 4.9 35 5.6 The factors most significantly associated with haemorrhage include advanced maternal age. Furthermore.33–2. 2.548 98.2 1.9 1. labour induction and augmentation.00 Yes 200 1.45 Premature rupture of the membrane No 17. No.18 Placenta previa No 18.69 P Eclampsia No 18. uterine rupture. retained placenta or its parts.

Risk factors for postpartum hemorrhage: can we explain the recent temporal increase? J Obstet Gynaecol Can. eds. Indonesia National Planning and Development Board. premature or post-term pregnancies. Boston. with or without pathologic edema. Jakarta: The Ministry. The Lancet. Maternal mortality for 181 countries. Kramer MS. Mass: Harvard University Press. Naghavi M. and high parity. Curr Opin Obstet Gynecol. This might suggest that respondents who though that they had any symptom of complications. eclampsia was the strongest risk factor of PPH. early identification and prompt treatment for pregnant women with hypertension by health workers during antenatal case visits. Jakarta: The Board. 1980–2008: a systematic analysis of progress towards Millennium Development Goal.7:446-50. Dahhou M. 7. Hogan MC. Central Bureau of Statistics (CBS). Reviani N. Antepartum and postpartum haemorrhage.9 In conclusion. In: Murray CJ. infections. Health dimensions of sex and reproduction. pre-term as well as post-term birth increased the risk of PPH. 1995. et al. Indonesia Demographic and Health Survey 1994. National Family Planning Coordinating Board. and obstructed labor. Factors influencing complication during delivery in Indonesia 2007 [Thesis]. Lopez AD. 375:1609-23. The risk of these complications was higher respondent lived in urban area compared those who lived in rural area. placenta previa. Vallerand D. Foreman KJ. et al. A road map to accelerate achievements of the MDGs in Indonesia. If uncontrolled. 2010. Practice Bulletin #76: Postpartum hemorrhage.7% of respondents were very active in attending of antenatal care (more than 4 times) and 21.33:810-9. Postpartum hemorrhage. 2010. eclampsia could lead to maternal death or cause growth restrictions of the fetus. Ministry of Health of Idonsia. Data on antenatal care visit shows 78. 6. 5. An earlier evaluation of the factors influencing complication during delivery in Indonesia using the 2007 IDHS dataset shows that surprisingly breaking of water excessive vaginal bleeding during delivery increased with increasing level of education. Ministry of Health and Macro International Inc. Our findings imply the need of increasing awareness on health and safe delivery. Eclampsia is a vascular endothelial disorder. Acceleration effort to decrease maternal mortality rate.70 Jekti and Suarthana Health Science Indones rupture. 2. Obstet Gynecol. In particular. visited antenatal care more frequently. Jakarta: CBS. 2010. Therefore. increasing education does not have direct correlation with an increase in knowledge about delivery complications. 2006. Abouzahr C. qualification of health services. which is clinically defined by hypertension and proteinuria. Eclampsia can range from mild to severe.108:1039-47. Indonesia. The 1994 Household Health Survey found the major causes of maternal deaths in Indonesia included haemorrhage. 8. 2011. 9.8 Our study revealed that eclampsia was the strongest risk factor of PPH. She also hypothesized that respondents choose better health services for delivery when they experience complications. The author argued that health aspects of health and safe delivery are not included in the subjects of formal education in Indonesia. 3. Other risk factors of PPH included premature rupture of the membranes. Adelaide: The Flinders University of South Australia. . 4. 1998:172-4. REFERENCES 1.3 % attended antenatal service less than the recommended three antenatal visits. American College of Obstetricians and Gynecologists (ACOG). 1998. eclampsia. Jouppila P. frequency of antenatal care attendance. We found risk of PPH increased with increasing level of education. 1995.

2:71-6) Key words: cesarean section. Risiko yang terkecil (96%) terjadi pada wanita yang pernah mengalami kejang atau pingsan (RRa = 1.Vol.96.1 Bastaman Basuki2 1 2 The National Institute of Health Resesarch and Development. Urban and rural ratio of c-section rate was 2. Wanita yang pernah dibandingkan yang tidak pernah mengalami sebarang tanda atau gejala komplikasi kehamilan berisiko lebih besar mengalami c-sesarea. Indonesia Abstract Background: In the last years. those who reported compared to those who did reported bleeding had 2.501 wanita. the frequency of cesarean section (c-section) has risen.9. Kesimpulan: Wanita yang pernah dibandingkan yang tidak pernah sebarang tanda atau gejala komplikasi kehamilan berisiko lebih besar mengalami c-sesarea. (Health Science Indones 2011. community perception. Wanita yang pernah mengalami dibandingkan yang tidak pernah mengalami perdarahan per vaginam berisiko 2.75-2.12. Moreover.com . Methods: Data were derived from the Basic Health Survey (Riskesdas) 2010. No. persepsi masyarakat. .mi@gmail.41-2.2:71-6) Kata kunci: seksio sesarea.9. pregnancy complications. Women who reported high fever had 2. The lowest risk (96%) was among those who ever had convulsion/fainted (RRa = 1.34]. Analisis mempergunakan regresi Cox dengan waktu konstan. komplikasi.73).33.73). The sub-sample was married or divorced women aged 10-49 years between January 1.8% among 20. Indonesia Corresponding author: Suparmi E-mail: suparmi. 95% interval kepercayaan (CI) = 1.3-lipat c-sesarea [risiko relatif suaian (RRa) = 2.1-lipat mengalami c-sesarea (RRa = 2. Women who reported than who did not report any signs or symptoms of complications during their pregnancies had a higher risk of c-section.96. Wanita yang pernah dibandingkan yang tidak pernah mengalami demam tinggi berisiko 2. Analysis used Cox regression with constant time.58).58). Sub-sampel dengan metode multistage stratified sampling di seluruh Indonesia di antara wanita yang menikah atau pernah menikah berumur 10-49 tahun yang melahirkan bayi antara 1 January 2005 sampai 31 August 2010.33. This study was aimed to identify several signs or symptoms of complications during pregnancy increased the risk of c-section (c-section). Faculty of Medicine Universitas Indonesia Abstrak Latar belakang: Pada beberapa tahun terakhir kejadian seksio sesarea (c-sesarea) meningkat.69-3. 2. Results: The c-section rate was 10. (Health Science Indones 2012. Conclusion: Women who reported any signs or symptoms of complications during their pregnancies had an increased risk of c-section. 2005 and August 2010 in Indonesia based on multistage stratified sampling methods. 95% CI = 1. Metode: Analisis ini memakai sebagian data Riset Kesehatan Dasar (Riskesdas) 2010. Rasio prevalensi kota dan desa ialah 2. 95% CI = 1. 95% CI = 1.34].12. 95% confidence interval (CI) = 1.501 women..1-fold increase risk of c-section (RRa = 2.69-3. 2. Tujuan analisis ialah untuk mengidentifikasi beberapa tanda atau gejala yang berbahaya selama kehamilan terhadap c-sesarea.8% di antara 20. 95% CI = 1. December 2011 Symptom of cmplications and risk of c-section 71 Signs or symptoms of complications in pregnancy and risk of caesarean section: an Indonesia national study Suparmi. Indonesian Ministry of Health Department of Community Medicine. Hasil: Prevalensi c-sesarea sebesar 10.3-fold for c-section [adjusted relative risk (RRa) = 2.41-2.5-2.

Women were classified as having a complete ANC if they mentioned height and weight measurements. Riskesdas 2010 is a cross sectional survey which provided specific information on the health Millennium Development Goals (MDG) according to the commitment of global health efforts at the national and provincial level. and 20. one field editor and data entry. Some indicators collected include nutritional status of children. METHODS The data analyzed originated from the Basic Health Survey (Riskesdas) 2010 of Indonesia.3 Furthermore. The subjects consisted of 69.2 Although c-section is considered relatively safe. working status. 50 women because their age were 50-59 years. and 10 subjects because of incomplete data. the impact of c-section trends might be modified by changes in population health or improvements in obstetric care. it poses a higher risk of some complications than a vaginal delivery. abdominal examination. c-section rates above a certain limit have not shown additional benefit for the mother or the baby.300 households. and demographic characteristics (i. (2) who did not have ectopic pregnancy. risks of certain peripartum complications have long been associated with c-section. convulsion/collapse. the frequency of cesarean section (c-section) has risen in the past few years.591 ever or still married women age 10-59 years. For this analysis. and others) Baby size was consisted of five subgroups based on mother’s perception of the baby size after birth (average. place of living and levels of expenditure per capita). Riskesdas 2010 study was approved by the Ethical Committee of National Institute of Health Research and Development (NIHRD) Ministry of Health of Republic of Indonesia. leaving 20. presented clinical complications related to c-section risk. large. and some studies have reported that high c-section rates could be linked to negative consequences in maternal and child heath. baby size at birth. Few reviewed community perceptions of medical complications during pregnancy related to c-section. 30 subjects were excluded because of ectopic pregnancy. Risk factor variables consisted of suspected complications during pregnancy. On the other hand. 2005 and August 2010. very painful stomach ache. and very large). access to drinking water sources.1 Prior studies reported an inverse association between c-section rate and maternal and infant mortality at population level in low income countries. antenatal care (ANC). malaria and tuberculosis. and two interviewers. education. Laboratory tests for diagnosis of malaria and tuberculosis were performed in the field at the respective referred public health centers. Each team consisted of one supervisor. The eligible population was all households in the entire Republic of Indonesia having equal probability of being included. Antenatal care was divided into two subgroups (complete and incomplete). Perception on signs and symptoms that indicate pregnancy was threatened based on mother’s report consisted of 6 subgroups (none.1. in addition. however. private. The interview was held in the respondent’s home. The interviewers consisted of 104 teams. very small. urine sample taken. For this analysis. women were classified as having a c-section if the c-section was either done at a government. term of delivery.501 subjects for this analysis. This study aimed to identify several community perceptions on signs and symptoms that indicate complications in pregnancy related to the risk of c-section.388 respondents.6 Sampling was multistage stratified sampling. as well as the safe and basic sanitation facilities. and .4 The trend toward increasing c-section suggests that the incidence of those complications might also be on the rise. Nationally representative sample of Riskesdas 2010 was 33 provinces with over 441 districts/cities of the total 497 districts/cities in Indoesia. or maternity hospital and if assisted by medical doctors.72 Suparmi and Basuki Health Science Indones In developing countries. (3) aged 10-49 years. bleeding.5 Most prior studies. small. The sub-sample included in the analysis were women meeting all criteria: (1) who gave birth of their last child between January 1. Data were collected through interviews and measure- ments. with 251. Specially trained interviewers collected data using the questionnaire. blood pressure measurement. maternal and child health status.e age group. high fever.

Several demographic factors and the risk of c-section Delivery Vaginal C-section (n=18. term as well as postterm pregnancy.8 Crude relative risk 95% confidence interval P 1. Working status was divided into housewife/student.5 88. high school or above were grouped together.165 2.7%).00 1.0 74. 2. the data were analyzed by Cox regression with constant time.859 9.47 Reference 2. private/government employee. Furthermore Table 1 noted that older. and more wealthy Table 1.9 4.21-4.00 2. and postterm if they had delivery in 10 months of pregnancy.404 3. Education was based on the last education obtained by the respondent (none. and others.8 80.833 3.25-1. Women were classified as aterm delivery if they delivered in 9 months of pregnancy.561 516 12.006 0.00 1. preterm if they had delivery in 7-8 months of pregnancy. living in urban area. 2034 years.000 0.800 2.28-2.003 5. and 35-49 years).217) n % n % Residence Rural Urban Age group 13-19 years 20-34 years 35-49 years Education None Primary education Secondary education or above Working status Housewife/student Private/government employee Farmer/fisherman/laborer Others Level of expenditure Lowest Second Middle Fourth Highest 9.063 767 185 202 203 296 420 560 738 5.723 8.0 software.000 0.9 16.0 25.5 19.5%). December 2011 Symptom of cmplications and risk of c-section 73 informed of signs of pregnancy complications.09 Reference 1.6 The analysis used STATA 9. farmer/fisherman/laborer.000 0. private/government employee.3 6. 2.424 0.6 4.00 1. Table 1 showed the women who had c-section rate was 10. and aged 20-34 years (70. RESULTS The youngest subject who had c-section was 16 years old.422 10.529 651 108 700 1. Maternal age was into 3 subgroups (13-19 years.00 1.1%/5.0 6.Vol.54-7. private/government employee or farmer/fisherman/laborer.54 1.000 0.5 16. Place of living was divided into urban and rural.94 2.889 4. Table 1 showed that the highest occurrence of c-section was found in women with 35–49 years of age.6 11.58 1.6 89.7 93.3 89.49 Reference 1. Most of the subjects had lower education (52.1 85.54 0.968 4.913 4.39-0. Level of expenditure per capita originally was divided into 5 levels.646 37 1.93 3.91 1.4 10.56 0.64-3.18 1.2%).001 0. living in urban area.09-2.5 90. higher parities. NIHRD gave permission to analyze part of Riskesdas 2010 data.7 10. complete ante natal care.14-2. primary and junior high school were grouped together into primary education.5 80.20 Reference 1.9 93.2 19.09 0.409 1. No.7 9.000 0.501 women.000 0.2 571 1.284) (n=2.88 3.81-1.73-2.73-5.94 1.43 5. and urbanrural c-section rate ratio was 2.274 3.3 90.5 96. with quintile 5 as the highest quintile and the lowest or poorest quintile was 1.46 0.000 0. preterm and postterm).1 95. Never and no primary education were grouped together into none.8% (2.0 93.206 3. primary education.217 among 20.761 1.5 83. secondary education or above.53 4.9 15.77 6. Term of delivery was divided into 3 subgroups (aterm.1 6.52 Reference 1.000 0. secondary education or above).90 0.3 4. To assess the risk of c-section.36-1. and has the highest level of expenditure per capita subjects.123 94.79 1.63 2.7 95.000 .5 9.48 3.

67 0.57 1.2 Adjusted relative risk* 95% confidence interval P 1.082 112 1.9 23.7 n 1. education.47 1.224 625 435 16.307 221 199 87 111 359 90.7 96.3 3.865 35 77 26 27 187 9.33 1.172 and 138/19.6 34.66 1.862 5.32-1.41-2.2 89.5 73.948 181 88 1.9 90.34 1.25-2.03 1. antenatal care completeness.000 0.3 1.75-2.000 0. .000 Table 3. Several gynecologic factors and the risk of c-section Delivery Vaginal (n=18.1 13.8 14.9 20.217) n % 1.172).217) % 12.493 540 % 87.000 0.31 1.56 1.6 91.5% (1.7 13.3 72. In the final model (Table 3).27 Reference 2. working status.00 2.94 0.284) n Parity 1-2 3-5 6-15 Pregnancy Aterm Preterm Postterm ANC completeness Incomplete Complete Baby size Average Very small Small Large Very large 11. The least were fever.057 3.00 1.000 0. complete ante natal care.7% (113/19.63 1.374 41 173 539 90 C-section (n=2.3-fold risk of experiencing c-section.34-2.26-1. The most common (1. revealed that compared to women who did not report complication before their labors.67 1.6 85.4 14.2 85.6%.458 13.000 0.1 77.99 Crude relative risk 95% confidence interval P 0. age group.00 3.172 respectively).8 77. 0. Sign or symptoms of complication during pregnancies that indicate threatened pregnancy and risk of c-section Delivery Vaginal (n=18.8 9. level of expenditure.59 Reference 0.61-0.5 26.01 1. Table 2.000 0. Women who reported high fever had 2.000 0.74 0.00 0.90-2.2 90.7 27.73 2.000 0.00 2.8 C-section (n=2.676 509 32 1.05 Reference 1.57 Reference 0. those who with preterm as well as postterm pregnancies.826 1.172). Table 3 showed that women who did not have any signs or symptoms of complications during their pregnancies were 93.4 65. and convulsions.89-1.1 79.81-2.000 0.43-5.96 2.22-0. and 1.8 10.221 0.21 2. 0.3 86.5 83.865/19.9 86.44 Reference 1. and baby size. The lowest risk was among women who reported very severe abdominal pain.284) n % Complication during pregnancy None Very severe abdominal pain Bleeding High fever Convulsion/collapse Others 17.5 16.2% women was very severe abdominal pain (256/19.12 2.851 366 1.31-1.3%) reported signs or symptoms of complication during their pregnancies was bleeding (276/19.000 0.21 1.000 0.69-3.000 *Adjusted for residence. all women who reported complications during pregnancy had a higher risk of experiencing c-section. On the hand.1 9. parity.85 1.0 80. and did not deliver normal baby were more likely to be c-section delivery.172).58 1.4 8.2 22.74 Suparmi and Basuki Health Science Indones were more likely to have c-section deliveries. Table 2 noted that women with higher parity were less likely to have c-section deliveries.49 1.0 19.612 810 17.

7 Bleeding. which was on average.37:41–8. particularly to Dr. 2. failure to progress in labor.9 times. fever. and demand to have caesarean section from the subjects as well as from the respective medical doctors. which was 5%.8 Indonesia is a developing country with both high rates of maternal mortality and a marked disparity in c-section rate between urban and rural women. women who reported any signs or symptoms of complications during their pregnancies that indicate pregnancy were threatened had an increased risk of c-section. Belizán JM.172. In conclusion. The least ones were fever. No. This number was higher than previous report (Indonesia Demography and Health Survey – IDHS 2007-2008) which noted that 89% out of 14.1 But this finding was almost similar to the best current estimate of the overall rate of c-section delivery in developing countries.Vol. and convulsion were relatively small percentage. and the ratio of c-section between urban and rural was 2. Levels and trends in cesarean birth in the developing world. cephalopelvic disproportion. REFERENCES 1. The low c-section rate in rural showed that those who are at greatest risk for obstetric complications do not have adequate access to the procedure as stated in a prior study. 3% had excessive vaginal bleeding.who. Stanton CK. on placenta previa and abruption. but these three complaints increased the risk of c-section by about 2-fold for each (relative risk of 2. and 1. Acknowledgments The authors wish to express their sincerest gratitude to The National Institute of Health Research and Development. Firstly. December 2011 Symptom of cmplications and risk of c-section 75 which had a 21% increase in experiencing c-section. the rate of women who had c-section was within range of the World Health Organization (WHO) recommendation that a nation’s c-section birth rate should be in the range of 5–15%. cord prolapsed. Lancet. 2006.pdf DISCUSSION Several limitations must be considered in interpreting the findings.6% and convulsion. Trihono for the use of datasets.7%.1 On the other hand. recommendation is questionable. 2006. On the other hand. Indonesia Ministry of Health. repeated caesarean sections. Holtz SA. Althabe F. this study used a national wide survey with a large sample consisting of 20. these three complaints are recommended to be considered as early warning potential factors which increased the risk of c-section and have to be detected during ANC visits. Caesarean section: the paradox. and 1% had fever. the IDHS report revealed among those who reported complications. [cited 2011 October 26].int/healthsystems/topics/ financing/healthreport/30C-sectioncosts. Our analysis noted that the rate of women who had c-section was 10. based on a study using nationally representative data from 82 nations with a median reference year of 1996. 2.7 Moreover. and multiple births. The c-section rate was found to be higher than previous reports based on calculated regional c-section rates in Southeast Asia. 2. birth defects. . In spite of these limitations.it/journals/ lancet/article/PIIS0140-6736(06)69616-5/full text World Health Report. Secondly.0. the Riskesdas 2010 did not have detailed risk factors data related to c-section. such as. data on complications during pregnancy and baby size were based on community perception of medical complications during pregnancy and baby size women perceptions. 0.12. the findings revealed the most common complaints was bleeding (1.1 Furthermore.96 respectively). this 2. three times as high as those among rural women. followed by very severe abdominal pains (1. Available at: http://www.3%). breech position.043 women reported no complications during their pregnancy. Therefore. this analysis was based on data from a national wide survey (Riskesdas 2010). Thirdly.5% out of 19. findings on urban-rural rate ratio was almost similar to the ratio among urban women in the developing world. The Organization [cited 2011 October 26].9 The finding showed that the percentage of women who did not have any signs or symptoms of complications during their pregnancies was 93. Available at: http://www. 3. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: overuse as a barrier to universal coverage. which was 12%. fetal distress.591 ever or still married women. Studies Fam Planning.2%).8 However. 368 (9546):1472-3.thelancet.33.8%.

9. Available from: http://www. 2008. 2007 October.2:436-7. Identifying barriers and facilitators towards implementing guidelines to reduce caesarean section rates in Quebec. 5. Cafferata ML. Indonesia Demographic and Health Survey 2007-2008. ORC Macro. Health consequences of the increasing caesarean section rates. Belizán JM.76 Suparmi and Basuki Health Science Indones 4. Barros A. Appropriate technology for birth. Jakarta. 85:791–7. Badan Pusat Statistik-Statistics Indonesia (BPS). 1985. BioMed Central. 2011. Basic Health Survey Report 2010. Chaillet N. Dugas M. The Ministry. Hirakata VN.gov/pubmed/17568221 Ministry of Health Republic of Indonesia.18: 485-6 [cited 2011 October 26]. of models that directly estimate the prevalence ratio. 6. Calverton. Epidemiology.ncbi. Alternatives for logistic regression in cross-sectional studies: an empirical comparison 7. et al. Bull World Health Organ.Althabe F. World Health Organization. 2003.nlm. 8.3:1-13. Lancet.nih. 2007. USA: BPS and ORC Macro. Maryland. Dubé. .

2. Banyak masyarakat yang memanfaatkan air minum isi ulang untuk memenuhi kebutuhan air minum sehari-hari. and color. This study presents the quality of refill drinking water assessment based on the examination of physical and chemical parameters in 2010. chloride. 2. temperature.2:77-80) Kata kunci: kualitas air. kesadahan. dan warna. Metode: Desain penelitian adalah cross-sectional. sulfate. (Health Science Indones 2011. suhu. Pada kajian ini disajikan penilaian kualitas air minum isi ulang berdasarkan pemeriksaan parameter fisik dan kimia pada tahun 2010. physical and chemical properties. All samples which did not qualify because the pH value was beyond the permitted limits and one sample because the content of manganese was above 0. Kesimpulan: Air minum isi ulang di Jabotabek sebagian besar memenuhi syarat atau layak untuk diminum. Ministry of Health from January to December 2010. klorida. Physical examination includes TDS (the amount of dissolved solids). Jabodetabek Corresponding author: Arifayu Addiena Kurniatri E-mail: arifayuaddiena@ymail.1% (28) samples did not meet the requirement set by the Miniter of Health decree. Pemeriksaan secara fisik meliputi TDS (jumlah zat padat terlarut). turbidity. (Health Science Indones 2011.4 mg / l. Each sample was assessed for physical and chemical content based on Miniter of Health decree Number 492/MENKES/PER/ IV/2010.4 mg/l. Many people use refill drinking water to meet the needs of drinking water daily. The sample is said not to meet the standard quality if one or more parameters have a value beyond the maximum limit. about 23. and organic compound KMnO4. Kementerian Kesehatan selama Januari-Desember 2010. Institute for Health Research and Development. Samples were obtained from the public who requested the examination of drinking water quality in the Laboratory of Pharmaceutical Technology at the Center for Basic Biomedical and Health. Jabotabek Abstract Background: Drinking water is increasingly scarce in urban areas.Vol. Sampel didapatkan dari masyarakat yang mengajukan permintaan pemeriksaan kualitas air minum di Laboratorium Farmasi di Pusat Biomedis dan Teknologi Dasar Kesehatan. Hasil: Di antara 121 sampel terdapat 23. mangan. Ministry of Health Abstrak Latar belakang: Air yang layak minum kian langka di perkotaan. sulfat. No. manganese. Chemical examination includes nitrites. fisik dan kimia. Water consumed by the public must meet the requirements of safe drinking water quality for health.com . Adapun sampel yang tidak memenuhi syarat karena kadar mangan yang tinggi dan pH yang terlalu rendah dan terlalu tinggi. Seluruh sampel yang tidak memenuhi syarat karena nilai pH di luar batas yang diperbolehkan dan 1 sampel karena kandungan mangan di atas 0. Samples that did not meet the requirement because of high levels of manganese. Pemeriksaan secara kimia meliputi nitrit. too low or too high pH. iron. besi. Masing-masing sampel dilakukan pemeriksaan kualitas fisik dan kandungan zat kimia berdasarkan PERMENKES Nomor 492/MENKES/PER/ IV/2010. Conclusions: Most refill drinking water in Greater Jakarta meets the quality requirement. Sampel dikatakan tidak memenuhi syarat jika salah satu atau lebih parameter memiliki nilai diluar batas maksimum.2:77-80) Key words: quality of water. pH. Air yang dikonsumsi masyarakat harus memenuhi persyaratan kualitas air minum yang aman bagi kesehatan. dan senyawa organik KMnO4. kekeruhan. December 2011 Quality of drinking water 77 Quality of refill drinking water in Greater Jakarta in 2010 Arifayu Addiena Kurniatri Center for Basic Biomedical and Health Technology. pH. hardness.1% (28) sampel tidak memenuhi syarat PERMENKES. Results: Among 121 samples. Methods: The study design is cross-sectional.

as a result of inadequate urban waste water treatment facilities. color of ≤ 15 mg / l. and color. Safe drinking water is when it meets the requirements for physical. Table 1 shows that the impropriety refill drinking water in Greater Jakarta was caused by two variables.5. water sources (springs) and others. The number of samples obtained during January-December 2010 was as many as 426 samples. it would cause health problems. In Jakarta for example. microbiological. By implementing that way. The requirements according to the Health Minister are as follows: TDS ≤ 500 NTU.5% of samples did not meet the requirements for drinking water. Currently besides industrial pollution caused by waste. In previous studies describing quality of drinking water in Greater Jakarta during the years 2007-2009. Samples analyzed were only refill drinking water and those with complete inspection data. KMnO4 ≤ 10 mg / l.3 Determination whether the drinking water met the quality requirement was by comparing each parameter against the maximum limit in accordance with the Minister of Health decree Number 492/MENKES/PER/ IV/2010. Many people use refill drinking water to fullfil their daily needs. Center for Basic Biomedical and Health Technology in 2010. Water supply in Indonesia such as piped water has not been evenly distributed in each region so that the community generally use ground water (wells).2 If contaminated water is consumed by the public. pH 6. manganese ≤ 0. Current problem is that drinking water is increasingly difficult to obtain. turbidity ≤ 5 TCU. chemical parameter: problem of toxic chemical compounds. pH. METHODS This study uses water quality data checks are performed at the Laboratory of Pharmacy. river water. the total number of samples analyzed was 148 samples. Analysis was conducted by Stata 9 statistical program.1 The sources of water becoming polluted by untreated industrial waste due to the use of excess capacity compared to renewal ability. manganese. chloride ≤ 250 mg / l. even the bodies of the river designated as a raw material of drinking water has been contaminated as well. heavy metals. that manganese is too high and the pH is too low and too high.3 mg / l. nitrite ≤ 3 mg / l. hardness. especially in urban areas. i. turbidity. chemical and radioactive materials contained in the mandatory parameters and additional parameters.5 to 8.78 Kurniatri Health Science Indones Water is a very basic requirement for human beings. biological parameter determined by the presence of pathogenic bacteria contained in the water. 121 samples were used in this study. this paper examines the quality assessment of physical and chemical parameters specific to refill drinking water in Greater Jakarta in 2010. chloride. thus determined eligible or ineligible quality of drinking water. turbidity. Study results provide information about physical and chemical quality of refill water so that water. If any parameter exceeds a specified threshold then it is concluded that water samples are not qualified or not good to drink. With so many business of refill drinking water. pollution caused by domestic waste has demonstrated a serious effect. Ground water has become unsafe due to contaminated drinking water material from septic tanks and surface water. the consumer is protected as well as the business of refill drinking water itself. iron ≤ 0. Chemical quality was checked by measuring the level of nitrite. iron. RESULTS Of the 426 samples of water quality inspections in 2010 at the Laboratory of Pharmacy. Test results vary widely in terms of physical and . water must be processed to eliminate or reduce levels of contaminated material to a level that is safe. Assessment of drinking water quality was carried out by examining the physical and chemical quality of each sample. discoloration and flavor. hardness ≤ 500 mg / l. Before consumption. and color. The study design is cross-sectional and type of experimental is laboratory research. and KMnO4 organic compounds in water samples. more attention is required to guard the quality of drinking water produced. it was found that 27.4 Following the review. sulfate. river bodies have been polluted by domestic sewage.e. Physical quality of the examined includes Total Dissolved Solids (TDS). sulfate ≤ 250 mg / l. Hence.4 mg / l.4 Samples were water proposed by communities of the Greater Jakarta area to be examined in the laboratory to obtain water quality certification. Mandatory parameters that must be followed by all providers of drinking water include:3 (1) physical parameters including TDS (Total Dissolved Solids). rain water.

the pH value should not be less than 6. Refill drinking water is generally made from water that has been treated with a variety of processes such as by ozonation. Therefore.9 100 100 n 0 0 0 0 0 0 0 1 28 0 0 No % 0 0 0 0 0 0 0 0.02 37. turbidity in the water is associated with the possibility of contamination by sewage.01 0. 2.23 4.6 Poor physical water quality can indicate what chemicals contained in water.62 0. water quality can only be seen from the physical and chemical parameters. adsorption by activated carbon filtration or membran (reversed osmosis).78 0 0 0 0 0 0.56 0. Screening/ filtration stage was instrumental in normalizing the pH value.01 0. Max.0 0. Water with high pH (above 8.5 Water treatment done in depots of refill drinking water in Greater Jakarta seemed to have been able to produce excellent physical quality of water. because at this stage both anions and cations that lead to high / low pH can be filtered.5-8.91 124.5) is acidic and not recommended for consumption because it may indirectly be bad for health. Another limitation was that the data of biological parameters was not obtained because it was done in other laboratories. 2.05 0.73 11.7 High content in water can cause water to become .84 50.61 4.97 121. The pH value of drinking water depends on the pH of raw water and the processing process.00 8.3 500 250 0. Quality of refill drinking water based on physical and chemical parameters Meet the quality requirement Parameter Unit Mean SD Min. Water that is alkaline usually contains excess ions that are not needed by the body. No. In addition.2 5.1 There are two parameters of the chemical that cause one sample that does not qualify.09 0.1 0 0 Physical TDS Turbidity Color Chemical Nitrite Iron Hardness Chloride Manganese pH Sulfate KMnO4 mg/l NTU TCU mg/l mg/l mg/l mg/l mg/l mg/l mg/l mg/l 87.e.5 8.03 100.Vol. CV (%) Standard n Yes % 100 100 100 100 100 100 100 99.0 1.80 0. However.86 500 5 15 3 0.4 6. except for pH.0 0.74 0. According to Permenkes 492/ MENKES/PER/IV/2010.2 0 0 290.1 168. the content of manganese and pH. seen from the CV> 20%. Water with low pH (below 6. i.77 0.01 6.28 2. and information regarding the origin of the sample was not recorded in full.5 21. Drinking water should not only be safe but the physical quality is also a priority.8 23.74 48.00 74. It can be seen in Table 1 where all samples meet the requirements of physical parameters.2 76.06 4.40 91.5 250 10 121 121 121 121 121 121 121 120 93 121 121 chemical parameters.19 0.5) is alkaline.02 28.0 57.5. In terms of aesthetics.89 500.37 40. Water turbidity for instance.5 3.5 or more than 8.00 100. samples were obtained during the months of January to December 2010 and the examination was performed by standard procedures.7 12.32 0.69 0. UV radiation.85 3. can be caused by the presence of organic materials and inorganic materials contained in the water like mud and materials derived from waste. low pH water is corrosive because it can dissolve metals that are not required by the body.0 0 5. DISCUSSION Limitations of this paper is that the data obtained was recorded data from the results of the proposed community water quality in 2010. December 2011 Quality of drinking water 79 Table 1.0 34.

2011 [citated 2011 November 17]. Rofiq I. Sitorus S. 6. 492/Menkes/Per/IV/2010 on drinking water quality requirements. [citated 17 2011 November 17].go. Minister of Health decree No.who. Indonesia/ .bppt. Indonesia. and reverse osmosis.go.id/ejurnal/ index.pdf. Herlambang AH. Indonesia. 3. Anwar D. WHO Guidelines for drinking-water quality 4th edition. 2009[citated 17 November 2011]. Available from http:// www.15:19-24. Ani Isnawati as Head of the Laboratory for her permission to use the data.3:83-92. Water quality and performance of processing unit in drinking water processing installation [thesis]. and smelling the metal manganese. Acknowledgments The author would like to thank the Laboratory of Pharmacy. A Rahmita. Institut Teknologi Bandung. Bandung. Indonesia. Drinking Water quality analysis by ozonization process. Geneva.php/JAI/article/view/57/10. Widiyanti NLPM. Available from http://www.itb. Year 2007-2009. REFERENCE 1. Indonesia.ac. Manganese in water can be removed by chlorination followed by filtration.5 mg / l whereas the requirement is 0.pdii. Athena.id/ admin/jurnal/62093032. so it can be said that excess manganese that occurs in this sample did not affect the physical quality of water. It is necessary for drinking water depots to normalize the pH and reduce the levels of manganese in their drinking water products.lipi.int/water_ sanitation_health/publications/2011/dwq_guidelines/ en/. Health Research Development Media.depkes. brown. Ministry of Health and Dra.2:1629.pusat3.3:64-73. refill drinking water quality in Greater Jakarta according to chemical and physical parameters was generally of good quality.80 Kurniatri Health Science Indones turbid.id/data/vol%203/ Ni%20 Putu%20_2. Water quality parameters that did not meet drinking water quality standard in refill drinking water were manganese and pH. 2009. Isnawati A. Indonesia. The Ministry of Health. This may occur because in the sample that does not qualify the parameter of manganese levels was 0. Sukar. in Singaraja. Health Ecology. Hendro M. 2005. Drinking water quality outlook in Jabotabek.ftsl.8 This study found one sample that had excessive levels of manganese. Available from http://isjd. 6:30-2. Excess levels of manganese was of very little difference. Mulawarman J Chemical. Bali. but did not find a sample that has turbidity and color that exceeds the maximum limit. 2006[citation 17 November 2011]. Indonesia.pdf. Available from http:// www.go.. 8. 5. 2004[cited 2011 November 17 2011]. Downloaded from http://ejurnal. WHO. ultraviolet. Water pollution and its managing strategy. Indonesia. Mariana R. JAI. Ristiati NP.litbang. Qualitative analysis of coliform bacteria on drinking water refill depot 2. Republic of Indonesia.4 mg / l. Center for Basic Biomedical and Health Technology. Water processing influence in normalizing acidity (pH) in drinking water refill depot.6 In conclusion. 4. 7. Indonesian J Pharmaceutical 2009.pdf.id/kk/rekayasa_air_dan_limbah_cair/ wp-content/uploads/2010/11/pi-w2-rahmita-astari15305049. Sukmayati A.

and the least was mixed infection (Ascaris lumbricoides. The key to worm eradication is to improve personal hygiene and environmental sanitation. The most frequent STH infection was Trichuris trichiura. tidak mencuci tangan sebelum makan dan tidak mencuci tangan dengan sabun setelah buang air besar mempertinggi risiko infeksi cacingan. Pemeriksaan tinja menggunakan metode Kato Katz dan wawancara menggunakan kuesioner.2 kali terhadap terinfeksi cacingan.04]. fingernail biting. sedangkan infeksi campuran Trichuris trichiura dan Hookworm sangat jarang. Yogyakarta Departement of Parasitology. No hand washing before meals as well as no hand washing with soap after passing stool also increased the risk of STH infection by 2.2-fold. Methods: A cross sectional study with purposive sampling method was carried out in a primary school children in a area of a Yogyakarta health Center from October to December 2009. (Health Science Indones 2011. Results: Two hundred and eleven subjects participated in this study.6%) had STH infection.1 Sri Sumarni.22-4. Universitas Gadjah Mada 3 Vector Borne Disease Control Research and Development Council. sedangkan cacingan Ascaris lumbricoides.22-4. Pengumpulan data dilakukan dengan survei tinja dan wawancara. cuci tangan Abstract Background: Intestinal worm infections transmitted through the soil are the most common infection among parasitic infections.8-fold) occurred among those with a habit of fingernail biting compared to those who did not bite fingernails [adjusted relative risk (RRa) = 2. (Health Science Indones 2011. 2.80. 95% confidence interval (CI) = 1. West Java Abstrak Latar belakang: Infeksi cacing usus yang ditularkan melalui tanah (Soil Transmitted Helminth-STH) merupakan infeksi tersering dan terbanyak di antara infeksi-infeksi parasit. Risiko tertinggi (2. Kunci pemberantasan kecacingan adalah memperbaiki higiene perorangan dan sanitasi lingkungan.Vol. December 2011 Risk factors for helminthiasis 81 Fingernail biting increase the risk of soil transmitted helminth (STH) infection in elementary school children Liena Sofiana. Hasil: Di antara 211 subjek. 95% interval kepercayaan (CI) = 1. This study aimed to identify several risk factors related to occurrence of Soil Transmitted Helminth (STH) infections in elementary school.80. and 52 subjects (24.co. Stool was examined by using the Kato Katz method and pupils were interviewed by questionnaires.8 kali lipat) terjadi di antara murid yang mempuyai kebiasaan menggigit kuku jari dibandngkan dengan yang tidak mempunyai kebiasan ini [risiko relatif suaian (RRa) = 2. kebiasaan menggigit kuku jari.6%) murid mengidap cacingan dan yang terbanyak adalah Trichusis trihiura. 52 (24. Universitas Ahmad Dahlan. The highest risk (2. Tujuan penelitian ini adalah untuk Mengidentifikasi faktor risiko yang meningkatkan infeksi STH pada anak sekolah dasar (SD).id . 2. Metode: Penelitian ini menggunakan desain potong lintang dengan sampel purposif. Kesimpulan: Kebiasaan menggigit kuku jari. Faculty of Medicine.2 Mara Ipa3 1 2 Faculty of Public Health.04]. Penelitian ini dilakukan di suatu SD di wilayah kerja Puskesmas di Yogyakarta pada bulan Oktober sampai Desember 2009. Ciamis. Subjek yang tidak mencuci tangan sebelum makan atau tidak mencuci tangan dengan sabun setelah buang air besar mempunyai risiko 2.2:81-6) Keywords: soil transmitted helminth. No. Conclusion: Fingernail biting and no hand washing before meals as well as no hand washing with soap after passing stool increased the risk of STH infections.2:81-6) Kata kunci: cacingan. Trichuris trichiura and Hookworm). hand-washing Corresponding author: Sri Idaiani E-mail: liena_manisku@yahoo.

1 In Indonesia. distance of toilet to water source/well. This is especially true during the growth and development of the children. using the toilet. Therefore worm infestations still pose a threat to the future of the children. the prevalence was 7.0 software was done to determine the risk factors for STH infections. They are transmitted through the soil and into the human body and more than one billion people worldwide suffer from worm infestation. Universitas Gadjah Mada. soap. although it is not considered a serious public health problem yet. but the impact is very severe. Ninety-five percent confidence intervals were based on the standard error of coefficient estimates. There were eight aspects for personal hygiene. school. low level of education and poor socio-economic level. Faculty of Medicine. especially in children. The study lasted 3 months from October to December 2009. inadequate sanitation.25. water storage. among others. wastebasket. The subjects were first grade primary school children.6%) had STH infection. and hookworms (Necator americanus). RESULTS A number of 211 subjects participated in this study. yard. METHODS A cross sectional study with purposive sampling method was carried out in a primary school. The stool sample was then covered with cellophane tape (22 x 30 mm) which had been soaked in a solution of green Gliserynmalachiet for 24 hours. The primary school was located in the area of Kulonprogo in Yogyakarta health center.5 There were ten aspects for sanitation of home environment clean water. Data of personal hygiene and sanitation were obtained through questionnaires filled out by the respondents. since it can affect the intelligence and mental development of children.8%.6 Cox regression analysis with constant time using STATA 9. using sandals/shoes. The number of primary schools in the Kokap I health center area is 25. bathing twice a day with soap.2 Several risk factors suspected to be related to the high incidence of STH are. poor knowledge. whip worms (Trichuris trichiura). Health Science Indones Soil Transmitted Helminth (STH) infections are the most common among parasitic infections. The fecal samples were collected in cooperation with the classroom teachers. and 52 subjects (24. is also quite high. and also geographic conditions suitable for breeding of the worms. while in an area served by another health center. Excess fluid on the edges of the cellophane tape was drained by placing the preparations upside down on tissue paper. consisting of 15 state primary schools (SDN) and 10 private primary schools. This survey was conducted with approval by the Ethics Committee of Medicine and Health Research. the number of STH cases. The stool preparation was thinned and flattened out. All the children were asked for fecal samples and then interviewed. Even though STH does not cause death. toilet. The children were asked to pass stool in the morning before going to school.82 Sofiana et al. and health behavior. usually infect children.4 The preparations were labeled (name of student. Stool that had been filtered was taken with a stick and then pressed with perforated cardboard (Kato cardboard) on a coded slide. drinking water. promptly collected the stool sample and come to the school as soon as possible. These were hand washing before meals. and kitchen. The teachers instructed the children to collect their stool in a pot that has been provided. The stool collected was examined by Kato-Katz method. fingernail biting. A risk factor was considered to be a potential confounder if the univariate test it had a P-value 0f <0. trimming fingernails. and date of execution) and then examined under a compound microscope. and considered as a candidate for multivariate model along with all known risk factors for STH infections. These intestinal worms.3 The purpose of this study was to identify the association of personal hygiene and the other factors to STH infections in elementary school children in the area of a primary health center in Yogyakarta. types of flooring. poor personal hygiene. Relative risks (RR) were estimated by the maximum likelihood. hand washing with soap after passing stool. A sample the size of a green bean was taken with a stick and placed on waxed paper (which is water impermeable) and filtered through a fine steel mesh (screen ware) approximately 3x4 cm. and using clean water for bathing & drinking. Yogyakarta.8%. even though it has been largely ignored by the community A report from one district in the province of Yogyakarta found the prevalence of worm infection in 2008 to be 9. such as roundworms (Ascaris lumbricoides). The STH infections were not only single infection (one type of worm . attitude.

072 0. The same increased risk for STH infection (2.0 76. Results of stool examination for Soil Transmitted Helminths infection Species of worms Ascaris lumbricoides Trichuris trichiura A.0 1.2-fold increased risk for STH infections.94-4.52-3.08-4.3 36.00 2.8 5. lumbricoides.44 1.0 33 19 26.8 50.7 75. trichiura & Hookworm A. Table 2. lumbricoides & T.2 50.Vol. Those who did not wash their hands before meals had a 2.6 75. using clean water for bathing & drinking.1 28.54-1.60 Reference 1. and Hookworm. Table 3 revealed four dominant risk factors that increased the risk STH infections.1 50.00 2.00 0.029 . T. 2.0 Table 2 showed that subjects with positive and negative STH infections were similarly distributed with respect to trimming of fingernails. trichiura T. subjects who did not wear sandals or shoes.850 142 7 141 8 142 7 139 10 74. Table 1 showed that the STH infection with the highest frequency was single infection of Trichuris trichiura and the lowest frequency was mixed infection of Ascaris lumbricoides. Table 1. No. and using soap for bathing. Trichuris trichiura.00 1. No hand washing before meals as well as no hand washing with soap after defecation also increased the risk for STH infection.925 0.0 48 4 49 3 45 7 42 10 25.0 23.9 50.39 Reference 0.29 0. Several personal hygiene characteristics and the risk of Soil Transmitted Helminth infections STH infection Negative Positive (n=149) (n=52) n % n % Trimming fingernails Yes No Using clean water for bathing & drinking Yes No Using soap for bathing Yes No Using toilet Yes No Using sandals/shoes Yes No 92 57 73. Those with a habit of biting their fingernails had the highest risk (2.8 1.9 100.2-fold) was found among those who did not wash their hand with soap after defecation.3 24. December 2011 Risk factors for helminthiasis 83 only) but also mixed type infections with 2 or 3 types of worms.99 Reference 0.4 25.08 1. or did not use the toilet were more likely to have STH infection compared to the reference group.7 63.2 72.8-fold) of STH infections compared to those who did not.66 P 1.8 27.6 74.95 0.06 1. trichiura & Hookworm Total Frequency 8 25 15 3 1 52 Percentage (%) 15.33-3.4 25. 2.0 Crude Relative Risk 95% Confidence Interval Reference 0.00 1. On the other hand.4 48.484 0.15 Reference 0.

4 40 41.3 42 23.009 98 51 123 26 88. The results showed that poor house sanitation was a risk factor for STH infections.16 1.0 13 11. especially in rural areas. The poor environmental sanitation surrounding the houses made it possible for the occurrence of continuous reinfection.1 10 52.3 56.14-4. Although all ages can be infected with worms. STH infections in children can be only a single infection (one type of worm only) or they can be mixed infections involving 2 or 3 types of worms. This condition will produce an accumulation of larvae in the body.84 Sofiana et al. After entering through the skin.009 0.22-4.7 81.5 52.6 12 11. This result was similar to a study in Malaysia that showed hygiene as a risk factor for the occurrence of Soil Transmitted Helminths.23 Reference 1. This result was similar to a study in the Karanganyar district. whereas Trichuris trichiura and Hookworms for 5-10 years. Outside the body the eggs will mature and ready to reinfect again for the same person or another person (another host).55 0.019 1. trachea.3 28 18.3 The high prevalence of STH was probably due to geographic and environmental sanitation of the area which were favorable for the proliferation of the worms. The eggs will exit the body along with the feces.5 24 48. Fingernails biting and several personal hygiene and risk of Soil Transmitted Helminth infections STH infection Negative Positive (n=149) (n=52) n n Fingernails biting Yes No Hand washing before meals Yes No Hand washing with soap after defecation Yes No House sanitation Good 140 9 93 56 76. Kulon Progo.000 DISCUSSION Soil Transmitted Helminth infection is a disease typical of tropical and sub-tropical regions.00 Reference 1.7 Adjusted Relative Risk 95% Confidence Interval P 1. Yogyakarta. .80 Reference 1. the highest prevalence can found in children.4 88. the larvae will be taken by venous blood flow to the lungs.0 1. The worms then produce eggs which will pass to the outside world along with feces to reinfect the person or another persons.21-3.00 2. Mixed infections usually indicate recurrent infections in these children. The larvae will then enter the alveoli.7 Reinfection of Ascaris lumbricoides and Trichuris trichiura in humans (self reinfection) are possible through food contaminated by infective eggs. These ingested eggs will hatch in the duodenum where the larvae will stick to the intestinal villi and move to the proximal colon or eventually to the entire colon.8 Poor personal hygiene was also found to be a risk factor for STH infections in primary school children in Kokap I health center. Health Science Indones Table 3. In a village reinfection of ascariasis in children under 10 years was found to be lower than in children the age of 10 years and over. urban slums and densely populated areas. and pharynx to be swallowed and passed to the small intestines.85 Reference 0.9 Poor personal hygiene will facilitate the occurrence of STH infections by continuous reinfection.6 58.04 0. Adult worms will burrow into the anterior part of the intestinal mucosa and begin to produce eggs. The occurrence of reinfection in children often resulted from direct contact with soil containing infective eggs. since Ascaris lumbricoides can be present up to more than 1 year. Reinfection of Hookworms in humans is through penetration of the skin.00 2.7 39 43.00 2.9 47.

[cited 2010 March 20]. 2008. Nakita. hookworms.5 Fingernail which dirty and infected the soil is containing infective eggs are medium in STH infection transmission. Helminthiasis can lower the intelligent of child. Indonesian. Available from http://www. 33: 3-6. Central Java in 1995. Yogyakarta. tapeworms and pinworms. The authors would also like to express their sincerest gratitude for Dwi Ciptorini and Dr. worms are commonly encountered roundworms. 3. Yogyakarta: Universitas Gadjah Mada. thread worms. Acknowledgments The authors wish to thank all subjects who willingly participated in this study. Indonesian. One aspect of personal hygiene which has a greater influence on STH infections was hand washing before meals. 2. Media Medika Indonesia. Gunawan. both new infection and reinfection.14 STH transmission them through dirty hands. Profile of Kokap I health center. 2009. Rudy. 2008.blogspot. licking/biting of fingers were significantly higher risk for A.14 In this study fingernails biting was found to increase risk factor for STH infection. poor people with unsanitary behavior have a greater possibility to be infected by all types of worms. REFERENCES 1. This was probably the result of the dry sandy soil conditions which was unfavorable for the growth of Ascaris eggs.13 In children. Kulon Progo.depkes. M. frequent infections directly via hands contaminated by soil containing infective eggs. Indah S (ed).11 This proved that the occurrence of STH infections is determined by man himself. lumbrcoides and hookworms in elementary school students.10 The results of this study differed from the results of a study conducted in Mataram. The transmission of Ascaris lumbricoides. trichiura infection. This finding was similar to other studies. Yogyakarta: Kanisius. Indonesian. [thesis].16 In conclusion. this is compounded if they are not accustomed to hand washing before meal using soap. Seluma. Suhartono. Relationship personal hygiene children in elementary school and environmental health conditions with helminthiasis in Air Periukan. fingernails biting and no hand washing before meals. 6. lumbricoides and T. Indonesian. Factors of associated with the incidence and intensity of Helminthiasis in elementary school children in Karanganyar. which showed that there was no significant correlation between personal hygiene and the prevalence of worm infections. Available from: http://mylovbaby. This is consistent with the theory that humans infected with Ascaris lumbricoides and Trichuris trichiura by swallowing infective eggs contaminate food. 5. the children most frequently diseased worms because usually their fingers inserted into the mouth or eating rice without washing hands. drinks and cutlery. . 4. [Internet]. whereas infection by hookworm larvae are through penetration of the filariform in the soil into the skin. 2009. but the occasional person stomach also contained adult worms. Gazali. No. Indonesian. Interpretation on healthy house in healthy house plan. because washing with soap can mechanically remove dirt along with parasites from the hands.Vol. Since poor personal hygiene is one of the factors that play a role in the STH infections. Health Center of Kokap I. Fingernails are usually to be the place of transmission of worm eggs from soil into the body.html. This result was similar to a study in Southern Nigeria. Juffrie for their technical assistance. Bengkulu. 1998. Muhammad. and substantial infection of A. after treatment was slow. as well as no hand washing with soap after passing stool increased the risk of STH infection.com/2009/01/kecacinganturunkan-kecerdasan-anak. Minister of Health act on helminthiasis control guidance.12 Hand washing before meals using soap and water played an important role in the prevention of STH infections.go. fingernails tucked worm eggs are likely to be swallowed when eating.15 Fingernails biting behavior is bad behavior and have a significant association of STH infection. Indonesian. 2.7 This was supported by the poor environmental sanitation of the houses state where most of the houses have floors of beaten earth which facilitated the occurrence of STH infections. Fingernails always be cut in two days and short to avoid the transmission of worms from hand to mouth. [cited 2009 August l3].10 Humans are infected with Ascaris lumbricoides and Trichuris trichiura through swallowing mature eggs from contaminated soil. December 2011 Risk factors for helminthiasis 85 This was probably caused by the spread of infection elsewhere outside the village Sentanan.id/downloads/ Kepmenkes/ KecacingandanFilariasis/. 2. Ministry of Health of Indonesia.

Medical Parasitology I (Helminthology). Southeast Asian J Trop Med Public Health [Internet]. Nmour J. Brown HW. 13. (Indonesian}. [Internet].86 Sofiana et al. Indonesian. com/?act=article&id=423. Pedo Herri editor. Jakarta: Gramedia. Illahude DH. Medical parasitology. . toilet of families and health environment toward the prevalence of Ascaris lumbricoides in Kasongan. Diagnostic of medical parasitology.A. Anthropogenic Indices of Soil Transmitted Helminthiasis among Children in Delta State. 9. Pribadi W. 1983. 2007.promosikesehatan. 2nd ed. Jakarta. Yogyakarta: Universitas Gadjah Mada. Available from: http://www. Agoes D. 1996. Bruckner DA. Pribadi W editor. Jakarta: Balai Penerbit Fakultas Kedokteran Universitas Indonesia. 17:72331. Hidayat T. Indonesian. Health Science Indones 7. 8. 2009. Sandjaja B.1997. Prestasi Pustaka. 14.C. Padmasutra L.th/seameo/publication. Human intestinal nematodes in the basic clinical paracitology. 15. Environmental health. Onojafe J. Indonesian. 10. Teoh ST. Gandahusada S. Southern Nigeria. Hillman E. Helminthology in medical parasitology. personal hygiene and intencity of worm disease with nutritional status in primary school in Mataram [thesis]. Indonesian. 2008. Jakarta: EGC medical book. 16. 11. Indonesian. 2002. Available from: http://www. Onggowaluyo JS. 2006. Iranian J Publ Health. Omu B.38:31-8. Noerhajati. Indonesian. [cited 2011 Juli 27]. Indonesian. Hidayah NI. Jakarta: EGC.htm.mahidol.ac. Socio-environmental predictors of soil transmitted helminthiasis in a rural community in Malaysia. 28:811-4. Garcia LC. Behavior of hands washing before meals and helminthiasis in elementary school children in the West Sumatra. medical parasitology. Medika. Impact of clean water providing. 2002.tm. editor.O. 12.

peralatan yang mahal dan waktu yang lama. and time-consuming. head squash. Polymerase Chain Reaction (PCR) dan Direct Fluorescent-Antibody (DFA) memerlukan keahlian yang tinggi. Universitas Gadjah Mada 3 Faculty of Biology.Vol. Universitas Gadjah Mada 1 2 Abstrak Latar belakang: Survei virologi pada nyamuk vektor dapat digunakan sebagai Sistem Kewaspadaan Dini untuk mencegah penularan Demam dengue di suatu daerah. IC could detect dengue virus antigen as sensitive as RT-PCR (sensitivity 100%). Conclusion: The IC method has a high sensitivity and high specificity compared with RT-PCR. A total of 22 artificially-infected adult Ae. The IC Streptavidin Biotin Peroxidase Complex (SBPC) assay using monoclonal antibody DSSE10 was applied in mosquito head squash to detect Dengue virus antigen. dengue Abstract Background: Virological surveillance provides an early warning sign for the risk of transmission in an area. (Health Science Indones 2011. dengue Corresponding author: Dyah Widiastuti E-mail: umi. Polymerase Chain Reaction (PCR) and Direct Fluorescent-Antibody (DFA) requires a high level of technical skill. Imunositokimia mendeteksi antigen virus Dengue-3 dengan sensitivitas yang sama dengan RT-PCR (sensitivitas 100%). Metode IC ini dapat digunakan untuk surveilans virus Dengue pada nyamuk vektor. aegypti mosquitoes of DENV 3 were used as infectious samples and 35 non-infected adult Ae. Hasil: Nilai Kappa menunjukkan kesepakatan yang baik antara dua orang pemeriksa (0. Tujuan penelitian ini untuk mengevaluasi sensitifitas dan spesifitas pemeriksaan imunositokimia dibandingkan metode Reverse Transcription-Polymerase Chain Reaction (RT-PCR) untuk mendeteksi infeksi Virus Dengue 3. Universitas Gadjah Mada (UGM) in May 2009 until October 2010. Faculty of Medicine. Sebanyak 22 Ae.1 Bambang Yunianto. aegypti mosquitoes were used as normal ones.com . DSSE10. Pemeriksaan imunositokimia Streptavidin Biotin Peroxidase Complex (SBPC) menggunakan antibodi monoklonal DSSE10 dilakukan pada sediaan head squash Ae . Faculty of Medicine.aegypti untuk mendeteksi antigen virus Dengue 3. expensive equipment. But IC was less specific than RT-PCR (specificity 91%) because some false positive results were found in this method. Laboratory tests for dengue virus infection on mosquitoes include isolation of the virus. (Health Science Indones 2011. aegypti yang diinfeksi virus Dengue 3 digunakan sebagai kelompok infeksius dan 35 nyamuk yang tidak diinfeksi sebagai kelompok non infeksius.2:87-91) Keywords: immunocytochemical. Results: The kappa value showed a good agreement between two observers (kappa value 0. Metode: Penelitian eksperimental dilakukan di laboratorium Parasitologi Fakultas Kedokteran Universitas Gajah Mada (UGM) pada bulan Mei 2009-Oktober 2010. This IC method may be useful for virological surveillance of dengue infected Aedes mosquitoes. 2. Suatu metode berdasarkan imunositokimia menggunakan antibody monoclonal DSSE10 memiliki beberapa kelebihan. Methods: An experimental study was conducted in laboratory of Medical Parasitology.1 Sitti Rahmah Umniyati. DSSE10. A method based on immunocytochemical (IC) using monoclonal antibody DSSE10 has several advantages. Pemeriksaan laboratoris untuk deteksi virus Dengue pada nyamuk seperti isolasi virus.azki@gmail. 2.2 Nastiti Wijayanti3 Banjarnegara Vector Control Research Unit. Kesimpulan: Metode IC memiliki nilai sensitivitas dan spesifisitas yang tinggi dibandingkan dengan metode RT-PCR. Pemeriksaan RT-PCR sebagai baku emas diaplikasikan pada toraks nyamuk. Namun spesifisitas IC lebih rendah dibanding RT-PCR (spesifisitas 91%) karena beberapa hasil positif palsu muncul pada pemeriksaan ini. head squash. National Institute of Health Research and Development Department of Parasitology. RT-PCR as a gold standard was applied in mosquito thorax.63).2:87-91) Kata kunci: imunositokimia. No.63). This study aimed to evaluate sensitivity and specificity IC assay compared with Reverse Transcription-Polymerase Chain Reaction (RT-PCR) as gold standard to detect Dengue Virus (DENV)-3 infections in mosquito Aedes aegypti. December 2011 Immunocytochemical assay and Dengue virus 3 87 Sensitivity and specificity of immunocytochemical assay for detection of Dengue virus 3 infection in mosquito Dyah Widiastuti.

respectively. 6. The major disease burden is found in Southeast Asia and the Western Pacific. 90% specificity for whole blood samples. DEN-2. and DEN4.7 Therefore. designated DEN-1. Inoculation procedures took place under a dissecting microscope using a calibrated capillary needle and syringe plunger. Faculty of Medicine.88 Widiastuti Health Science Indones Dengue is a prominent disease in tropic and subtropic areas. highly sensitive and specific. Central Java province. They were collected at 5. and 7 days after inoculation and separated into caput and thorax. Direct detection of dengue antigen. The Anopheles mosquitoes were used as negative control tissue because they are not the vector of dengue virus. while caputs were kept at -70ºC for IC test.5 Laboratory tests for detection mosquitoes infected with dengue viruses include isolation of the virus and demonstration of a specific viral antigen or RNA. Faculty of Medicine. Three-day old adult females Ae. Isolation of the virus is the most definitive approach.3% sensitivity.6 Therefore.6 Detection of nucleic acid is an alternative method to detect infected mosquitoes. such as a thermalcycler. RT-PCR was applied in mosquito thorax. a method based on immunocytochemistry (IC) involving enzyme conjugates such as peroxidase and phosphatase in conjunction with either polyclonal or monoclonal antibodies has been developed to detect dengue antigen. Jakarta. aegypti mosquitoes were used as normal ones. such as the Direct Fluorescent-Antibody (DFA) test is labor-intensive and requires fluorescent microscope and cryo-freezer. Three days old adults female Ae.8 In this study. Monoclonal antibody against DENV-3 was produced by the Dengue Team of Universitas Gadjah Mada (UGM). UGM. albopictus3 and Ae. the newly developed MAbs DSSE10. polynesiensis4. Dengue virus type 3 (H-87) in C6/36 cell lines was obtained from Naval Medical Research Unit 2 (NAMRU-2). This study aimed to evaluate sensitivity and specificity IC assay compared with RT-PCR to detect Dengue Virus-3 infection in mosquito Aedes aegypti. Aedes (Ae. Virological surveillance provides an early warning sign for the risk of Dengue virus transmission in an area. and are timeconsuming. were used in staining mosquito head squash. This method has 94.) aegypti is considered the main vector because this species is closely associated with human habitation. METHODS An experimental study was conducted in laboratory of Medical Parasitology. DEN-3. aegypti from non-endemic area of DHF and Anopheles mosquitoes from Salatiga district. IC is useful in detecting dengue virus infection. Dengue viruses are transmitted to humans by the bite of infective female mosquitoes of the genus Aedes. This molecular technique is rapid. UGM from May 2009 until October 2010.6 However PCR requires a relatively expensive equipment. aegypti were collected by manual aspirators for use in the experiments. Negative controls comprised uninfected Ae.2 DEN-3 has been recognized as the predominant serotype in many recent epidemic occurrences of DHF in Indonesia. were reared to adults in the laboratory of Medical Parasitology. such as Ae. aegypti on dry filter paper. are also involved. This IC method is a common laboratory technique that uses antibodies that target specific peptides or protein antigens in the cell via specific epitopes. Infected mosquitoes were held in small cylindrical cages covered with mosquito netting. but in some regions other Aedes species.9 Mosquitoes were immobilized over wet ice for 5-10 minutes before being injected with virus suspension in the membrane area of the intrathoracic. and they were incubated at 27±1°C and a relative humidity of 88±6% and maintained on 10% sucrose for 7 days. aegypti were experimentally infected with DENV-3 using a sterile parenteral inoculation technique. Polymerase Chain Reaction (PCR) is one technique available for the laboratory diagnosis of dengue infection. A total of 22 artificiallyinfected adult Ae. aegypti mosquitoes of DENV 3 were used as infectious samples and 35 non-infected adult Ae. which recognize NS1 of dengue virus serotype 3 (DEN-3). Eggs of laboratory colony Ae. equipment. but the techniques involved require a relatively high level of technical skill. .1 There are four antigenically related but distinct serotypes of dengue virus.

the longer the incubation time). 2. For reliability. The preparation was dried in room temperature for around 30 minutes. Drops of mounting media were added on the preparation and covered with cover glass. 2.Vol. . meaning there is no DENV-3 antigen inside these mosquitoes. Germany). Sensitivity and specificity were measured based on Hermann formula. and then washed with tap water. Afterwards. Figure 1 showed IC staining positive result on A (5 days). then 100 mL Mayer hematoxyllin (counter stain) was added. When it was already dry.11 Preparation was fixed with cold methanol (-200C) for 3-5 minutes and washed with PBS.11 The preparation was incubated with ready to use streptavidin-peroxidase-complex reagent for 10 minutes and then washed twice with PBS for 2 minutes. If the preparation showed a brown color. Laboratory mosquitoes infected with DENV-3 were dissected into 2 parts (head and thorax) on day 5. 100mL biotinylated universal secondary antibody was added. 6. The expected size of 538 bp was identified as being of DENV-3 respectively. incubated for 1-3 minutes. 400x. incubated in 100 mL peroxidase substrate solution (DAB) for 2-10 minutes (the thicker the preparation. To eliminate the endogenous peroxidase activity. The preparation was then soaked in alcohol.12 RESULTS All head squash preparation of infectious groups showed positive result based on IC (Figure 1).1 mg/ml) was used. Each object glass can be filled with 10-15 caputs. Faculty of Medicine UGM. The microscopic examinations involved two observers. The cover glass was removed.5 μg/ml). The second observer was the researcher. aegypti from infectious and non-infectious group were put on the object glasses then pressed under cover glass with the eraser part of a pencil. the preparation was ready to be evaluated under light microscope with magnification of 40x. These groups were used as noninfectious group. and then washed twice with fresh PBS for 2 minutes. Then it was washed twice with (fresh) PBS for 2 minutes.11 One hundred mL primary antibody (DSSE10 1:10 monoclonal antibody) was added to the preparation (adjusted until all part was soaked) and incubated on damp tray at room temperature (250C) for 60 minutes or overnight in the refrigerator. Electrophoresis was set at 100 volts/cm2 and was run for 30-45 minutes. Meanwhile if the preparation showed blue or pale color (as in the negative control) the preparation did not contain DEN viral antigen. The first observer was an experienced technician of Medical Parasitology laboratory. and C (7 days) post-inoculation and negative result on non-infected mosquito (D). 100x. it was fixed with cold acetone (-200C) in freezer for 3-5 minutes. the preparation was soaked in peroxidase blocking solution (1 part of hydrogen peroxide 30% + 9 part of absolute methanol) at room temperature for 10 minutes. DENV-3 infection in Ae. washed. and the object glass was put into a bottle filled with alcohol 70%. Each mosquito thorax was amplified by RT. Most of head squash preparation of non-infectious group showed blue and pale brain tissues. Preparation was incubated in prediluted blocking solution for 10 minutes in room temperature (250C).10 The RT-PCR product was analyzed by agarose gelelectrophoresis on a 1. Inter observer agreement result shown in Table 1. For the DNA size marker. Dengue viral RNA in mosquitoes were detected by reverse transcriptase polymerase chain reaction (RT-PCR) using DENV-3 -specific primers. it meant that the preparation contained DEN viral antigen. and then soaked in xylol. 100 bp DNA ladder (0. and the preparation was incubated at room temperature (250C) for 10 minutes. meaning there were no DENV inside these mosquitoes. and 1000x. All of RT-PCR product of uninfected mosquito showed negative result.5% agarose gel (invitrogen) containing ethidium bromide (0.PCR to detect dengue virus. B (6 days). December 2011 Immunocytochemical assay and Dengue virus 3 89 RNA extraction was done in accordance with the protocol of High Pure Viral Isolation Kit (Roche. No. Caputs of Ae.63). and then washed with tap water. The first and the second observers were in agreement for detecting Dengue viral antigen on head squash preparation by immunocytochemistry using mABs DSSE10 (Kappa value was 0. Validity and reliability was determined based on kappa value by Landis and Koch. then dried in laminary flow. an agreement has achieved for kappa between two observers. and 7 days post-inoculation. aegypti was shown as discrete brownish granules between the whole brain tissues.

The mAb DSSE10 reacts to non-structural protein (NS1). the probability of samples noninfected with DENV-3 was 100% if diagnostic test result showed negative at IC assay. This is probably because the dried cells exhibit an overall lower antigen density.7 This difference in sensitivity value may be caused by the different preparation between head squash and blood smears. The monoclonal antibody used in this study was secreted by DSSE10 clone belonging to IgG class and IgG1 subclass.14 Table 2 showed that IC has good sensitivity (100%) and good specificity (91%). In contrast. The monoclonal antibody was secreted by a single hybrid (DSSE10) which was generated from the third fusion recognized as DENV complex specific epitope and showed no cross-reactivity to Chikungunya and Japanese Enchephalitis antigens based on Western blotting analyses. All head squash preparations of infectious groups DISCUSSION Table 1.3% sensitivity and 90% specificity. In addition. Head squash preparation was dried by wet-fixed smear. Table 2.11 The detection of DENV-3 antigen in mosquitoes by IC assay using monoclonal antibody DSSE10 has high sensitivity (100%). Air dried preparation often exhibits relatively weak immunoassaying.13 The IC stains are indispensable for problem solving in detection of infectious agent. Sensitivity and specificity of immunocytochemical assay RT-PCR (+) (+) Immunocytochemistry Total (-) 22 0 22 (-) 3 32 35 Total 25 32 57 Sensitivity = 100% Specificity Positive predictive value = 88% predictive value = 100% = 91% Negative . A “true positive” stain shows chromogen deposition in cells or structures that truly contain the antigen of interest. meanwhile blood smear preparation was dried by air drying. analysis showed probability that the samples infected with DEN virus was 88% if diagnostic test showed positive result at IC assay. Furthermore. Inter-observer agreement of immunocytochemical assay Observer 2 (+) (-) (+) 15 0 16 (-) 10 32 41 Total 25 32 57 Observer 1 Total Kappa value = 0. it is critical to be aware of a true positive stain and a false positive stain. Detection of Dengue virus in human thick blood smears by IC using monoclonal antibody DSSE10 gives 94. In order to evaluate them appropriately.63 Immunocytochemistry is a powerful method for the identification of proteins or antigen in cells and tissues.90 Widiastuti Health Science Indones Figure 1. which was more sensitive than the detection in human thick blood smears. a “false positive” stain is one where the chromogen is localized to cells or structures that in reality lack the antigen of interest.

social and economic problem in the 21st century. Halstead SB. Monitoring of dengue viruses in field-caught Aedes aegypti and Aedes albopictus mosquitoes by a type-specific polymerase chain reaction and cycle sequencing. Stead RH. Yogyakarta. Sutaryo. so this assay could be done in every laboratory and more cost-effective. Sweet BH. So.239:476-81. 1-2 [cited 2011 July 11]. The focus immunohistochemistry.php?option=com_content&do_pdf=1&id=148 Chow VT. IC process is easier than PCR. To eliminate endogenous peroxidase activity in this study was by the pretreatment of the tissue section with hydrogen peroxide prior to incubation of primary antibody. 14. Landis JR. Fontenille D.3:878-82. 2001. Pathogenesis of dengue: challenges to molecular biology. Immunocytochemistry using monoclonal antibody DSSC7 for pathogenesis of Dengue virus infection and transovarial transmission and virologic surveilance of Dengue vector [dissertation].15 When the number of dengue infection in mosquitoes increases the Local Health Office should make an effective vector control program to prevent the virus introduction to the human populations. Gubler DJ. Emerg Infect Dis. Diagnostic methods for detection & isolation of Dengue viruses from vector mosquitoes. 2005. Singapore Med J. 3rd ed. Besides. Biometrics.7:66-74. No. Rapid detection and serotyping of Dengue virus by multiplex RT-PCR and real-time SYBR green RT-PCR. false positive staining. 4.propath. Wahyono D. 13. Am J Trop Med Hyg. Rosen L. 2006. True positive vs. Farmilo AJ. 7.23:1153-60. Calisher CH. Yogyakarta. Available from: http://www. Faculty of Medicine.5:578-860. Science 1988. Yogyakarta. Umniyati SR. 1974.2007. Thayan R. 2009. Univ Gadjah Mada. Epidemic Dengue/Dengue hemorrhagic fever as a public health. 12. Carpinteria (Ca): DAKO Corporation. it needs further study to evaluate the application of immunocytochemical assay for detection Dengue virus infection in mosquito head squash in the field level to develop an effective early warning system for Dengue Fever prevention. head squash preparation of IC assay could be stored for along times. Chow noted that by detecting of Dengue virus infection in the mosquito vectors before its introduction into the human population it was possible to predict an outbreak six weeks in advance of the occurrence of the first human case in Singapore. 8. This method has a high sensitivity. 2. J Clin Microbiol. Indonesian. . Yong YK. Toto JC. Chong HT. 2.com/ index2. Report of RUT-3 Year I. Therefore. 1992. Indonesian. Gubler DJ. Production of monoclonal antibodies against Dengue virus 3 for DHF patients and vector. high specificity and good inter observer agreement. The IC assay has several advantages over the PCR method. The measurement of observer agreement for categorical data. 2001. Am J Trop Med Hyg. Koch GG. et al. Immunochemical staining methods. 1998. Univ Gadjah Mada. 2. Trends Microbiol. a potential new Dengue vector in Southern Cameroon. Lanciotti RS. 6. 3. 33:159-74. IC assay does not require specific equipment such as thermalcycler. Indian J Med Res. 2002. However Immunocytochemical stains in this study showed false positive in 3 samples of non-infected mosquitoes. Rosen L. 1954. editor. Boenisch T. Samuel PP. Detection of Dengue virus in mosquitoes would give valuable information as early warning system to prevent Dengue Fever transmission. The use of mosquitoes to detect and propagate Dengue viruses. Umniyati SR.Vol. 10. December 2011 Immunocytochemical assay and Dengue virus 3 91 The main cause of non-specific background staining is endogenous peroxidase activity which is found in many tissues and can be detected by reacting fixed tissue sections with DAB substrate13. Indonesian. 5. Rapid detection and typing of Dengue viruses from clinical samples using reverse transcriptase chain reaction.10:100-3. 2010. 48:662-68. 9. Yong R. 11. Tyagi BK. 30:545-51. with these advantages. p. Univ Gadjah Mada. REFERENCES 1. Sekaran SD. 1977. 2001. Miller RT. et al. First. Evaluation of immunocytochemical assay to detect Dengue virus infection on thick and thin human blood smear [thesis]. Aedes (Stegomyia) albopictus (Skuse). In conclusion. 15. IC has a chance to replace other method of dengue virus detection. Sabin AB.123:615-28. Gubler DJ. Chan YC. Rozeboom LE. Am J Trop Med Hyg. immunocytochemical assay could be used in detection DENV-3 infection on mosquito head squash. Mulyaningrum U. The Transmission of Dengue by Aedes polynesiensis marks. Moreover.

Hasil: Sebanyak 112 spesimen dari 4277 spesimen kasus ILI didapatkan hasil positif influenza dengan metode kultur. We evaluated the percentage of concordance between positive culture results vs its RT-PCR results. we learned that there was disagreement between virus culture and reverse trancriptase polymerase chain reaction (RT-PCR). Subangkit Centre for Biomedical and Basic Technology of Health.6%. Jl. Pada penelitian ini juga ditemukan bahwa 30. Jakarta 10560 Abstrak Latar belakang: Adanya perbedaan hasil antara kultur virus dengan real-time polymerase chain reaction (RTPCR) yang digunakan dalam surveilans influenza-like illness (ILI) menunjukkan perlunya mengevaluasi hasil kultur virus yang didapatkan dengan hasil RT-PCR sebagai pembanding. Vivi Setiawaty. influenza. Pawestri. Methods: The ILI specimens obtained from 20 ILI sentinels in Indonesia in 2007-2008. Hasil positif kultur virus dibandingkan dengan hasil RT-PCR berdasarkan persentase kesamaan hasil. Atlanta.Tujuan penelitian ini adalah untuk mengevaluasi apakah kultur virus masih dapat diandalkan untuk studi surveilans ILI. RT-PCR. Identifikasi kultur virus dilakukan dengan menggunakan metode hemaglutinasi dan hemaglutinasi inhibisi. Virus culture identification was conducted with hemagglutination and hemagglutination inhibition methods.4% of positive result using real-time RT-PCR were not detectable by virus culture. Conclusion: Virus culture was still essential and considerably efficient to support real-time RT-PCR detection in ILI cases in Indonesia although the positive Influenza results by virus culture less than RT-PCR.2:92-5) Key words: influenza-like illness. Health Science Indones Virus culture and real-time RT-PCR in identifying influenza viruses from influenzalike illness cases in Indonesia 2007-2008 Irene L.92 Indalao et al. A/H3N2 and A/H5N1) and Influenza B. Kesimpulan: Metode kultur masih relevan untuk surveilans ILI meskipun hasil positif Influenza dari kultur virus lebih sedikit dari pada hasil positif Influenza yang terdeteksi dengan metode PCR.4 % (n=112) hasil real-time RT-PCR yang ditemukan positif influenza tidak dapat dideteksi oleh metode kultur. Real-time RTPCR using primers were specific for influenza A (A/H1N1.com . culture Corresponding author: Vivi Setiawaty E-mail: vilitbang@yahoo. There was 69. NIHRD-MOH. influenza. A/H3N2 and A/ H5N1) dan influensa B. RT-PCR. RT-PCR menggunakan primer yang bersifat spesifik untuk influensa A (A/H1N1. Results: A number of 112 influenza positive in culture method from 4277 ILI specimens were compared with real-time RT-PCR result. USA. This implies the need to evaluate whether virus culture is still a relevant method to be used in ILI surveillance. We also found that 30. Hana A. Primer disediakan oleh Center for Disease Control and Prevention. (Health Science Indones 2011. Abstract Introduction: From the influenza-like illness (ILI) surveillance in Indonesia. (Health Science Indones 2011. Kesamaan hasil positif influenza kultur virus dibandingkan dengan real-time RT-PCR adalah 69.2:92-5) Kata kunci: influenza-Like Illness. Percetakan Negara 23. The sequence of these primers was provided by the CDC. Metode: Usap hidung dan usap tenggorok didapatkan dari 20 sentinel ILI di Indonesia selama tanun 20072008. Indalao.6% of virus culture result was in concordant with real-time RTPCR result. kultur.

Since 1999. has served as the national referral laboratory in Indonesia for influenza.6-8 RT-PCR provides a specific and sensitive method for detection of influenza viruses A and B and discriminates between virus subtypes. A/H1N1. headache or body aches. but most of them were focused only to see which one had the highest sensitivity or specificity.12 In this study. throat. USA). December 2011 Virus culture and real-time RT-PCR 93 Influenza-Like Illness (ILI) is a disease that shows influenza symptoms. B.3 Specimens usually used in this detection methods are nasal. this research was directed to evaluate whether virus culture method was still relevant to be applied in ILI surveillance.5. Ministry of Health (NIHRD). There were several researches that also aimed to compare result between different influenza detection methods in Europe and America. sore throat. METHODS Nasal and throat swabs were collected throughout Indonesia from 20 ILI sentinels who operated as primary health services in Indonesia. such as cough. The objective of this result was to evaluate the percentage of concordance between RT-PCR and virus culture. RT-PCR was considered more sensitive than by culture and ELISA.6 Meanwhile. Germany) was used to extract the specimens according to manufacturer’s instruction. Center for Biomedical and Pharmaceutical Research and Development.1 The surveillance of ILI cases is important because it detects influenza virus in patient. our institute used two different methods. The molecular method used in this study was Quantitative Reverse Transcriptase Polymerase Chain Reaction (qRT-PCR) utilizing Thermal Cycler IQ5 (Biorad. the RNA strand has to be reverse-transcribed into cDNA (complement DNA) first using the reverse transcriptase enzyme.3 It could also detect whether there was antigenic drift or shift. other disease with similar symptoms. Reverse trancriptase (RT-PCR) is a method for molecular detection recommended by the United States. NIHRD. the isolation from the cell line and the identification of the virus could be done.7 Cell culture also has been suggested to be performed to obtain early and late in the season influenza virus isolates which in turn is important to make sure that suitable vaccine strains will be available for the following year. ILI surveillance has to be maintained with reliable detection method.2. Although detection of influenza virus using virus culture requires time more than PCR up to 2 weeks.8-10 a considerable tool for influenza surveillance. NIHRD has conducted ILI surveillance as one of its main research activity. Viral culture is done by using 112 positive results from 4277 specimens obtained during 2007-2008. The reagent was one step qRTPCR Superscript III with Platinum Taq Polymerase . takes several hours to perform and is considered not suitable for lower level of expertise. Each specimen was screened by RTPCR prior to virus culture. however. Since most people suffered with influenza symptoms is not diagnosed or even seeks treatment. so that it will screen not only influenza cases. and rectal swabs. Although. but also. when the specimens added to the cell line. This isolated virus could be identified by serological method as type A or B with hemaglutination inhibition test.Centers for Disease Control and Prevention (CDC) to identify influenza virus infection in ILI cases. such as Influenza A Virus and Respiratory Syncytial Virus. which is to amplify the influenza virus RNA genome using a pair of oligonucleotide primers in order to generate copies of a certain DNA sequence. Indonesia. Virus culture was done in biosafety cabinet class (BSC) IIA within BSL2 Influenza Laboratory.6 They also used different detection object.4 The National Institute of Health Research and Development.5. 2. QiAmp RNA viral mini Kit (Qiagen. This study was not aimed to determine which was the best detection method between those two methods. this technique requires a high level of skill and complex laboratory infrastructure. runny or stuffy nose. but not an influenza disease. in RT-PCR. After the designated time. Jakarta.11 Influenza virus which may be contained within these specimens. but to evaluate whether virus culture was still reliable as an alternative test for RT-PCR. A/H3N2. Five sets of primers and probes which are syntesized by Invitrogen and Sigma (USA) were treated to the specimens to detect Influenza A.5 The principle of this method is similar to Polymerase Chain Reaction (PCR). in the other hand. will adhere directly to the cell and will infect other cells. 2.Vol. namely Real Time RT-PCR and Virus Culture. No. it was believed to be useful as alternative detection method which is necessary to avoid false negative results.9 The virus culture is considered a sensitive and useful technique for diagnosis of influenza virus.

B/Shanghai were supplied by WHO along with positive control. the percentage number of type and subtype of influenza virus from RT-PCR against virus culture was calculated by dividing the number of positive influenza in virus culture with number of positive result in RT-PCR. Cell culture was inoculated and passaged in two series to allow propagation of the virus. The denaturation step was done at 950 C for 5 seconds. subsequently. negative control.7 % was positive IBV by RTPCR but negative by culture. Forty five PCR cycles were applied in this procedure.e. Specimen was transported using Hank’s solution (GIBCO/Invitrogen. The concordance percentage was meant to give information how many positive result obtained from virus culture was actually have the same results with RT-PCR.4% of negative result by virus culture which could be identified by RTPCR as positive influenza. whereas the percentage numbers were not less than 50 %.4% phenol red (Sigma..94 Indalao et al. Therefore.12 RESULTS The comparative analysis between culture virus and RT-PCR of 112 positive influenza by RT-PCR were 70 (62. In total. The percentage was obtained by dividing the number of positive influenza in virus with number of positive result in cultureRT-PCR. from 112 specimens positive result based on RT-PCR. USA). Ltd. Based on these results. A/H3N2 (1 of 2) and B (70 0f 101). then 950 C for 2 minutes (taq inhibitor activation). there were only 78 positive influenza specimens according to culture. mostly. B/ Malaysia. The significance of the concordance between these results could be quantified to see the efficiency of virus culture against RT-PCR. Furthermore. USA) in it.2% streptomycin (Invitrogen. The discordance results could be found that four out of 112 (3. lack of the rapid transportation since Indonesia is an archipelago . USA) with 0. and Receptor Destroying Enzyme (RDE) Denka Seiken Co. We understand that RT-PCR method is an expensive method compare to culture. Health Science Indones (Invitrogen. Table 1. The identification of virus culture was held using Hemagglutination and Hemagglutination Inhibition assays based on World Health Organization guideline in influenza virus culture and characterization.10 The reference antigen and antiserum A/H1N1. USA) and 0. in influenza virus culture and characterization package. Negative results by virus culture shown on table 1 can be detected by RT-PCR. The cell line used in this culture was Madin Darby Canine Kidney (MDCK) cell (NAMRU II). The amplification procedure were as follows: 5 μl extracted RNA of each specimen was treated by 500 C within 30 minutes (reverse transcriptase activation).6%) was identified as IAV by RT-PCR but negative by culture. the quality of the specimen either due to sampling method. USA). These specimens were cultured to identify the type and subtype of influenza virus. and the annealing step was performed on 550 C in 30 seconds. 27.5%) Influenza B Viruses (IBV).6%) and also for influenza A/H1N1 (7 of 10). However the results from this study showed that virus culture was still considered as a reliable detection method since the percentage numbers of the consented results. there was 30. A/H3N3. This would mean most of the RT-PCR’s results were also could be identified with virus culture although the virus culture is a time consuming method. seven out of 112 (6. We collected data of virus culture which reported positive results during ILI surveillance 2007-2008. There were several reasons to explain about these phenomena i. The concordant percentage of virus culture to RT-PCR was relatively high (69. Table 1 showed that there were negative PCR results identified as positive IAV (A/H1N1 and H3N2) or IBV by culture method.2% penicillin (Invitrogen. The result difference between RT-PCR and virus culture Culture A/H1N1 A/H3N2 Influenza B virus Negative TOTAL RT-PCR A/H3N2 Influenza B virus 0 0 1 0 0 70 1 31 2 101 A/H1N1 7 0 0 3 10 DISCUSSION There was a concordance between the virus culture and RT-PCR result as there were matched positive results between virus culture and RT-PCR. we compared them with their RT-PCR result. were around 60%. 0.1%) were Influenza A Virus (IAV) by both methods.

and antigen detection for the diagnosis of upper respiratory tract infections due to influenza viruses. Evaluation of PCR testing of ethanol-fixed nasal swab specimens as an augmented surveillance strategy for influenza virus and adenovirus identification. 2002:40:2051-6. J Clin Microbiol. frost eh.321:736-7. 2001. Sumarno. et al. Ministry of Health of Indonesia. Pope W. Steininger C.pdf 2002.59:21520. 3rd Edition. J. the quickvue influenza test. and clinical case definition to viral culture and reverse transcription-PCR for rapid diagnosis of influenza virus infection. Clin. 3. No. Med. Mucosal immunology. Ratih Renindya Putri. J Clin Microbiol. Sri Susilowati. Maldeis N. Krafft AE. Evaluation of the directigen Flu A_B test for rapid diagnosis of influenza virus type A and B infections. Microbiol.gov/flu/ symptomps. Kundi M. 10. 2007. . NIHRD and ILI-SARI study team for their support and technical experties in this research. http:// www. Chan KH. Herrmann B. Rapid virological surveillance of community influenza infection in general practice. 5. J Clin Microbiol.7.42:1181-4. World Health Organization.39:196-200. 14. 6. Rowe SA. et al. Valette M. Role of cell culture for virus detection in the age of technology. Effectiveness of reverse transcription-PCR. 2003. Hawksworth AW.9 7 9 3 7 B 4 FA 8 3 C / 0 / manualonanimalaidiagnosisandsurveillance. comparison of the directigen Flu A_B test. et al. 1999. 2004. DS.4 A D 0 . Magnard CM. 2. 2. WHO manual on animal influenza diagnosis and surveillance. 2001. 7. 12. Virol. Data were entirely the property of NIHRD. Ginocchio CC.int/NR/rdonlyres/EFD2B9A72 2 6 5 . REFERENCES 1. virus culture was still essential and considerably efficient to support real-time RT-PCR detection in ILI cases in Indonesia although the positive Influenza results by virus culture less than RT-PCR. Aberle SW.43:1768-75. Reed DE. Van Elden LJR.Vol. virus isolation. December 2011 Virus culture and real-time RT-PCR 95 country. 8. 2005. Herrler G. Triyani. J. et al. Schipper P. Advance in Disease Surveillance. Acknowledgments This research was a part of the ILI and Severe Acute Respiratory Infection Study conducted by The National Insitute of Health Research and Development (NIHRD). J Clin Microbiol. Russel K. Larsson C. Simultaneous detection of influenza viruses A and B using real time quantitative PCR. 9. et al. US CDC. J Clin Microbiol. Wallace LA. Nijhuis M. Oerip Pancawati. and Sinta Purnamawati from Laboratory of Virology. cell culture.www. Clin Microbiol. BMJ. Griffin M. Tang YW. 2002. 2:67. who . enzymelinked immunosorbent assay for diagnosis of Influenza A virus infection in different age groups. Simultaneous detection and typing of Influenza Viruses A and B by a nested reverse transcription-PCR: Comparison to virus isolation and antigen detection by immunofluorescence and optical immunoassay (FLU OIA). Wirgart ZB. 20:49-78. Early detection of Influenza Like Illness: Developing a multi-variate 4.41:3487-93.cdc. 2007. Shaffer LE. In conclusion. et al. approach. J Clin Microbiol. Carman WF. Boston: Elsevier Academic Press.B C 9 8 .htm. Walker J. Aymard M. Ruest A. 11. or the nature of the specimen itself. 2007. Michaud S.gov. Deslandes S. Influenza symptoms. These factors might cause low concentration of viral RNA or RNA degradation and lead to negative result in RTPCR.5. et al.39:134-8. Compans RW. Comparison of two nested PCR. Surveillance of childhood influenza virus infection: What is the best diagnostic method to use for archival samples?. this event could be evidence for the capability of virus culture in propagating the viral load so that they could be detected by virus culture method. Rev. We thank to Agustiningsih. Leland. Ministry of Health of Indonesia in collaboration with United States of Centers for Disease Control and Prevention (US-CDC)-Atlanta. et al.40:1675-80. 13. 2002.wpro. 2. Frisbie B. 2005.13 Nevertheless.

runny nose. 0. dan 23.54.58. 95% interval kepercayaan (CI) = 1. Therefore.97-2. those who ever had than did not have fever for the last two days had 42% more risk of influenza A (RRa = 1.2:96-100) Kata kunci: Influenza A. Oleh karena itu gejala klinik sangat penting untuk mendiagnosis secara dini influenza A. Tujuan penelitian ini untuk mengidentifikasi gejala klinik dominan yang berkaitan dengan influenza A di Indonesia. The aim of this study is to identify additional dominant symptoms associated to influenza A in Indonesia. Metode: Penelitian potong lintang. sore throat Corresponding author: Roselinda E-mail: roselinda@litbang.depkes.7. and ever had fever are dominantly associated with influenza A. Data dan spesimen dikumpulkan oleh petugas paramedik atau medik puskesmas dari subjek rawat jalan dengan gejala ILI (batuk dan demam). Pemeriksaan Spesimen dilakukan di Pusat Rujukan Influenza Nasional di Jakarta.58.082). runny nose. cough. Results: Of 2728 specimens.2:96-100) Key words: influenza A. Those who had than did not have runny nose symptom had 3. Kesimpulan: Selain demam dan batuk. in the early stages is difficult to differentiate influenza to influenza-like illnesses.54. who had fever (38o or more) and coughing in purposive selected 20 Health Centers in 19 provinces of Indonesia during year 2009. Nyoman Fitri Center for Biomedical and Basic Technology of Health. those who had than did not have it had 54% more risk of influenza A (RRa = 1.42. P = 0. Pada model terakhir terungkap bahwa subjek dengan pilek dibandingkan dengan yang tidak pilek berisiko 3. 95% CI = 0. 1802 had complete data for this analysis. National Institute of Health Research and Development Ministry of Health Republic of Indonesia Abstrak Latar belakang: Pada tahap awal infeksi. P = 0. subjek dengan riwayat demam dibandingkan tanpa riwayat pernah demam dalam dua hari terakhir berisiko 42% lebih besar menderita Influenza A (RRa = 1. runny nose.59.e. 95% CI = 0. influenza A yang dapat menimbulkan pandemi.63). Paramedics and medical staff identified the ILI cases and collected specimens.6 kali lipat Influenza A [risiko relatif suaian (RRa) = 3.95-2.97-2. cough. Health Science Indones Several dominant clinical symptoms associated with Influenza A in Indonesia Roselinda. Conclusion: In addition to fever and coughing.go. 95% CI = 0.069). and 23. In term of sore throat.96 Roselinda and Fitri et al. sore throat.34-9. Hasil: Sebanyak 1802 subjek berdata lengkap untuk analisis influenza A dari 2728 subjek dengan gejala ILI.63].59. muscle pain.069). P = 0.42.082). (Health Science Indones 2011. keluhan pilek dan nyeri tenggorok. (Health Science Indones 2011.1% (416 subjek) didiagnosis positif influenza A. the dominant clinical symptoms are the important keys to predict influenza A infection in patients with influenza-like illnesses (ILI). Methods: The eligible subjects of this study were outpatient who had ILI symptom.95-2. 95% CI = 0.07. Penentuan Influenza A dengan real time RT-PCR. i.6-fold risk of influenza A [adjusted relative risk (RRa) = 3. dilakukan di 20 puskesmas sentinel yang dipilih secara purposif di 19 propinsi di Indonesia tahun 2009.34-9. muscle pain. 95% confidence interval (CI) = 1. Laboratory tests for RT-PCR were performed at the National Influenza Center in Jakarta. Subjek dengan nyeri tenggorok dibandingkan dengan yang tanpa nyeri tenggorok berisiko 54% lebih besar menderita Influenza A (RRa = 1. serta riwayat pernah demam dalam dua hari terakhir merupakan faktor risiko dominan yang berhubungan dengan Influenza A. Furthermore. Seangkan.id ..1% (416 subjects) diagnosed positive influenza A. sore throat Abstract Background: Influenza A has a potential to become a pandemic. sangat sulit dibedakan dengan influenza-like illness (ILI) yang lain.

For each provinces appointed one health center except Papua which had two health centers that were chosen purposively. sore throat. The symptoms were similar with common seasonal influenza. further examination in laboratory is needed to reveal the type of influenza and the sub-type if the result is influenza A. 18-34. B. Another pandemic occured in 2009 caused by a new subtype of H1N1 (swine flu). Valencia. 35-49. sore throat. such as fever or history of fever accompanied by cough. (5) and close to airport for easiness shipping to the regional laboratory or the nasional referral laboratory. New subtypes of influenza viruses may occure through processes called antigenic drift and antigenic shift. RT-PCR and Culture test are taking much time. 2. muscle pain and or dyspnea. The QIAamp Viral RNA kit (QIAGEN. CA) was used to extract viral RNA according to the manufacture manual. This study aimed to identify additional dominant symptoms associated to influenza A in Indonesia. runny nose. There are little known about factors related to influenza A. December2011 Clinical Symptoms Associated with Influenza A 97 Influenza-like illness (ILI) is a medical diagnosis of possible influenza or other illness with a set of common symptoms and therefore a significant source of morbidity and mortality worldwide.4 Since influenza A has similar symptoms with ILI. They also obtained demographic data and clinical symptoms from patients. All of the specimens were shipped to the regional laboratory in four provinces or to the national referral laboratory in Jakarta. there are 16 different HA subtypes and 9 different NA subtypes. they are A. Statistical analysis: Of the people enrolled (n=2728). influenza virus subtype H5N1 pandemic (bird flu) occured in Indonesia.1. influenza type A is more threatening because it can cause pandemics. The criteria to select the health centers included: (1) high prevalence of upper respiratory track infection.3 Influenza type A viruses are divided into subtypes (strains) based on two proteins on the surface of the virus. Additionally. even for the rapid test that has low specivicity and sensitivity for influenza A. muscle pain and dyspnea. We also collected the other symptoms which occured among the subjects: history of fever. Since influenza A viral infection can cause severe influenza-like illness among exposed people.Vol.3. Specimens were refrigerated (4°C) and shipped weekly with a strick condition. and C. 2. Before shipping. and 50-82 years old).2 There are three types of influenza based on the main virus that caused. Positive specimens were inoculated into cell culture using Madin Darby Canine Kidney (MDCK). These symptoms were obtained by observation and or asked by special trained paramedic or medical doctor during the subjects visited the health centers. Trained paramedics collected nasal and throat swabs from the patients. All of the virological and epidemiological data were collected and analized at the Virology Laboratory in Center for Biomedical and Basic Technology of Health. Informed consents were obtained from subjects. We . Therefore. virological and epidemiological surveillance are needed to understand the impact of influenza A virus among people with ILI symptoms in Indonesia. Additionally. swab of specimens were placed into sterile Hanks’ Balanced Salt Solution (HBSS) as viral transport media (VTM). All of the specimens were tested for influenza by realtime reverse-transcription polymerase chain reaction (rRT-PCR) assay. (2) human resources availability for ILI surveillance. The initial symptoms of influenza are similar to ILI. Influenza type A dan B have similar early symptoms that can cause epidemics and have high case fatality rates as well. (4) well documented reporting system. RT-PCR and Culture test as the gold standard for influenza[2]. only 1802 samples can be included in this study. METHODS A cross sectional study was conducted on cases that included into the ILI surveillance in 19 provinces in Indonesia in 2009. Influenza is an infectious disease caused by Orthomyxoviridae viruses that affects birds and mammals. 1317. Doctors seldom tell patients to confirm the result to the laboratory tests such as rapid test. Currently. It has been known that laboratory tests are very expensive. it will be too late to realize that patients have influenza A viral infections. Furthermore. runny nose. No. Procedures: Subjects with symptoms of fever (38° C or more) and cough who presented at primary health centers (outpatients) were enrolled once a week. we need clinical symptomps to give us high predictions about influenza A in patients. These proteins are called hemagglutinin (HA) and neuraminidase (NA). For this analysis age were categorized into five groups (6-12. A confirmed case was efined by a positive result of a realtime reverse-transcriptase polymerase chain reaction (rRT-PCR) test. In 2005. (3) cooperative and willingness to participate. Influenza A viruses can cause diseases with common symptoms that mostly will be neglected by people.

00 1.001 0.23 1.96 1.196 374 1.98 Roselinda and Fitri et al.94 0. sore throat.07 0.023 0.031 0.41 Reference 1. Male subjects and those who had muscle pain than sore throat more likely had increase risk to be influenza A. and ever had fever are dominantly associated with influenza A.00 1.97-2. Similar condition is shown between subjects age 18-34 years and 6-12 years old. and 23.29 1.59 1. Several demographic.58 Reference 0.53 Reference 0.011 0.16 95% confidence interval Reference 0.34 0.876 0.069 *Adjusted each other among risk factors listed n this Table . Those who had and did not have runny nose symptom had 3.191 Tabel 2.46 P 0.00 1.1% (416 subjects) diagnosed positive influenza A.082 Reference 0.012 197 219 210 70 94 34 8 113 303 400 16 97 319 Relative risk 1. Table 1.34-9.71-1.16 1.95-2.45-0. Health Science Indones excluded uncomplete data and patients under 6 years old because we could not acquire information from them about muscle pain.490 0.056 0.96-1.02-1.00 1. subjects of age 13-17 and 35 or more had more likely increase risk to be influenza A.42 Reference 1.93-1.012 410 258 27 389 97 319 45 47 P Adjusted relative risk* 95% confidence interval 1.58 Reference 0. 1802 had complete data for this analysis.58-1. We performed data analyzed using Cox regression using Stata released 9. those who ever had fever than did not have fever had 42% more risk having influenza A.14-0.63 Reference 0.00 1. Relatioship between clinical symptoms and risk of Influenza A Influenza A Negative Positive (n=1386) (n=416) Runny nose No Yes Sore throat No Yes Ever had fever for the last 2 days No Yes 190 1. Our final model (Table 2) reveals runny nose.58 0. those who had and did not have influenza A was similarly distributed with respect to dyspnea. those who had than did not have it is 54% more risk to be influenza A.00 0.99-1. Table 1 shows that in general.91 0.76 0. RESULTS Of 2728 specimens. Compared to age 6-12 years old.17 0.00 3.65 0.54 1. clinical symptoms and risk of Influenza A Influenza A Negative Positive (n=1386) (n=416) Gender Female Male Age group 6-12 13-17 18-34 35-49 50-82 Muscle pain No Yes Dyspnea No Yes Sore throat No Yes 725 661 643 141 322 176 104 455 931 30 56 374 1.6-fold to be Influenza A.120 0.00 1. In term of sore throat. Furthermore.

4. Hoffmann C. 2. Symptoms of influenza can start quite suddenly one to two days after infection.htm. and muscle pain (n=302). for this study we did not analyze for combination of symptoms. No. 2009.htm#AntiviralMedications Cao B. Third. 2005. In contrary. myalgia. 2006. Furthermore. Influenza (Flu) Antiviral Drugs and Related Information [cited 2011 November 18]. cough.8 However.18:808-15.2 It is difficult to differentiate influenza to influenza-like illnesses in the early stages of these infections. Moreover. . 2006. similar distribution is shown between subjects age 6-12 years and 18-34 years old (P = 0. and cough are the most common symptoms for influenza. Centers for Disease Control and Prevention. Male subjects had more likely increase risk to have influenza A. 2003.1. Management of influenza symptoms in healthy adults. RT-PCR test has more sensitivity in detection and ability to identify which influenza A subtypes. 361: 2507-17. we did not include fever and cough as examined symptoms because those symptoms had been included in CDC protocol for influenza. Indonesia. Mao Y. New York: McGraw-Hill. close observation into ILI surveillance in 2009 offered some dominant symptoms (runny nose.11 In conclusion. Compared to age 6-12 years old. They said that the most common symptoms for influenza feverishness.8 Unlike viral culture or rapid test. Monto et al. et al. Available from http://www. in a study stated different result.11 In addition. and weakness. Center for Biomedical and Pharmacy and Directorate of Communicable Disease and Environment.10 Another study imply that malaise. However. Rose DN.cdc. Harrison’s Principles of internal medicine. cough. Preiser W. and acute onset had a high predictive value of influenza.5 These symptoms may include fever. rapid diagnostic tests have a sensitivity of 70–75% and specificity of 90–95% when compared with viral culture. Therefore. fda. ILI surveillance team (laboratory. Paris: Flying Publisher.9 Our study reveals that among individuals with influenza A. also stated fever and cough as the best predictors. we only studied five symptoms.gov/drugs/drugsafety/informationbydrugclass/ ucm100228. CDC recommends RT-PCR for influenza for surveillance purposes. and CDC Atlanta for funding this ILI surveillance. 5.Vol. 8. Lastly to Vivi Setiawaty for her reviewing the final draft of this manuscript and her suggestion. body aches. Guidance on influenza-like ilness (ILI) epidemiology and virology surveilance in health center and hospital. First. every subject must have fever and cough. et al. sore throat (n=319).6 According to the CDC.7. It is a very small number if we compare to the number of symptoms that have been known. cough. 16th edition. subjects of age 13-17 and 35 or more had more likely increase risk to be influenza A. Longo DL. Kamps BS.5 One study suggested that during local outbreaks of influenza. Understanding the symptoms of the common cold and influenza. The center. Therefore. Eccles R. fever. Influenza report 2006. Dyspnea are distributed similarly between those who had and did not have influenza A. in our study we could not use fever and cough as variables because they are included in ILI definition. Wang J. http://www. 2.5:718-25. the most frequent reported symptoms were runny nose (n=389).6 Rapid laboratory tests can be used to detect influenza A. J Gen Intern Med. Li XW. 6. in a study analyzed combination of symptoms and revealed that combination of fever. Govaert et al. Lancet Infect Dis.490). and ever had fever) that can be used in order to predict influenza A in patients. Jakarta. N Engl J Med. Rothberg MB. 7. Male subjects and those who had muscle pain than sore throat more likely had increase risk to be influenza A. Acknowledgments The authors wish to thank all subjects who participated in this study. Second. He S.gov/flu/index. data manajemen and data collection). Clinical features of the initial cases of 2009 pandemic influenza A (H1N1) virus infection in China. Kasper DL. 2005. REFERENCES 1. especially muscle and throat. Eccles and Cao et al.5. December2011 Clinical Symptoms Associated with Influenza A 99 DISCUSSION In interpreting our finding there are some limitation that must be considered. and dyspnea. Interim guidance for influenza surveillance: prioritizing RT- 2. especially during the influenza season. 3. the prevalence will be over 70%. sore throat. it is not frequently experienced because the test itself is usually expensive. Fauci AS.

Dinant GJ.cdc. Clinical signs and symptoms predicting influenza infection. et al. 1998. The predictive value of influenza symptomatology in elderly people.100 Roselinda and Fitri et al. Gravenstein S. Aretz K. Available from http://www. 11. PCR testing in laboratories [cited 2011 November 10]. Govaert ThME. Arch Intern Med. Fam Prac. Health Science Indones 9. et al. 2000.gov/h1n1flu/screening. Govaert ThME. . 1998. et al. htm Monto AS. 10. Aretz K.160:3243-7. The predictive value of influenza symptomatology in elderly people.15:16-22. Fam Prac. Dinant GJ.15:16-22. Elliott M.