Hari Pneumonia se-Dunia ke X

12 November 2018

Pencegahan Pneumonia
 Bahayanya pneumonia

Fungsi paru  oksigen

jaringan paru rusak

oksigen kurang

kematian
15 negara dengan kematian akibat
pneumonia terbanyak di dunia

Sumber:
One is too many: ending child deaths from pneumonia and diarrhea. UNICEF. 2016.
 Pneumonia Penyebab Kematian Utama pada
Usia 0 - 11 bulan dan 0-59 bulan
No Causes of Death (ICD 10), 0 - 11 months % No Causes of Death (ICD 10), 0-59 months %
Disorders relating to length of gestation Disorders relating to length of
1 18.9 1 14.0
and fetal growth (P05 – P08) gestation and fetal growth (P05 – P08)
Intrauterine hypoxia and birth asphyxia Diarrhoea and gastroenteritis of
2 14.8 2 11.1
(P20, P21) presumed infectious origin (A09)
3 Pneumonia (J12 – J18) 9.7
Intrauterine hypoxia and birth asphyxia
Diarrhoea and gastroenteritis of presumed 3 11.0
4 9.2 (P20, P21)
infectious origin (A09)
4 Pneumonia (J12 – J18) 9.5
Congenital malformations of the heart
5 5.8 Congenital malformations of the heart
(Q20 - Q24) 5 5.9
(Q20 - Q24)
6 Respiratory distress of newborn (P22) 4.3
6 Meningitis (G03) 3.5
Fetus and newborn affected by maternal 7 Respiratory distress of newborn (P22) 3.2
7 factors and by complications of pregnancy 2.4 Accidental drowning and submersion (W65
8 2.0
labour and delivery (P00 – P04) – W74)

8 Meningitis (G03) 2.2 Fetus and newborn affected by maternal

factors and by complications of
Haemorrhagic and haematological disorders 9 1.9
9 1.7 pregnancy labour and delivery (P00 –
of fetus and newborn (P50 – P61) P04)
10 Diseases of the digestive system (K56) 1.4 10 Diseases of the digestive system (K56) 1.5
4
The National Institute of Health Research and Development-Ministry of Health Republic of Indonesia. Indonesia Sample Registration System 2015. Lembaga Penerbitan
Balitbangkes. 2017: pg.21 (2)
Kematian karena Pneumokokus dan Hib pada anak usia 1–59 bulan
Cakupan vaksin penting terkait pneumonia
Dosis ke-3 vaksin Hib Dosis ke-3 vaksin PCV

Meningkatnya cakupan intervensi yang berimpak tinggi dan

penguatan sistem kesehatan merupakan faktor kunci
penurunan angka kematian balita

UNICEF. Committing to Child Survival: A Promise Renewed Progress Report 2015.

 Mengapa Kelompok Usia Muda Berisiko terhadap IPD
dan Penyakit Pneumonia akibat Pneumokokus?
Anak usia <2 tahun
•Menurunnya antibodi yang didapat dari Ibu saat lahir1
•Sistem imun yang belum matang1
•Kolonisasi kuman Streptococcus pneumoniae nasofaring yang tinggi2

CVD=cardiovascular disease; IPD=invasive pneumococcal disease.

1. Offit PA, et al. Pediatrics. 2002;109:124-129. 2. Garcia-Rodriguez JA, et al. J Antimicrob Chemother. 2002;50(S2):59-73. 3. Caruso C, et al. Immun Ageing.
2009;6:10. 4. Kyaw MH, et al. J Infect Dis. 2005;192:377-386. 5. Musher DM. Streptococcus pneumoniae. In: Mandell GL, et al, eds. Mandell, Douglas, and
Bennett’s Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA; 2010:2623-2642.
6. Bewick T, et al. Thorax. 2012;67:540-545.
7
Penanggulangan Pneumonia
Framework Pengendalian Pneumonia
PROTECT
Lindungi
• ASI ekslusif selama 6 bulan

• Nutrisi yang cukup sehingga anak memiliki gizi baik

• Semua BALITA mendapatkan vitamin A 2x setahun setiap Februari

dan Agustus di Posyandu

• Mengurangi polusi asap rumah tangga dari tungku dan kompor.

Bersihkan kompor secara teratur.

• Tidak merokok di dalam rumah.

• Kebiasaan mencuci tangan dengan air bersih

Vitamin A
Cegah defisiensi vitamin A
Anak yang terpapar rokok, 4 kali lebih tinggi
memerlukan rawat inap karena masalah
pernapasan dan 2-3 kali lebih tinggi dalam
hal kunjungan ke gawat darurat karena
masalah pernapasan
PREVENT
 Pencegahan:
Hilangkan Faktor Resiko
ASI (-)
Gizi buruk
Defisiensi vit A
Imunisasi (-)

Usia ekstrim Berat lahir rendah

peningkatan
risiko
Umur ibu muda
Anak banyak pneumonia

Urban/kepadatan Cuaca dingin

Prevalensi tinggi Pajanan polusi udara

karier nasofaring • Asap rokok
bakteri yang patogen • Asap bakaran biomas
• Polusi udara lingkungan
Cegah !!!!

• Imunisasi dasar pada bayi terutama DPT (Difteri,

Pertusis dan Tetanus) dan Campak cegah
komplikasi pneumonia
• Pemberian vaksinasi Hib dan Pneumococus pada
bayi dan anak.
• Pemberian zinc pada anak dengan diare.
• Pencegahan HIV/AIDS pada anak
• Profilaks kotrimoksazol pada anak dengan HIV/AIDS
Kematian akibat Penyakit yang Dapat
Dicegah dengan Vaksin pada Estimated
Chart Title
Anak deaths in 2015 1

Pneumococcus In children younger than 5 years

•S pneumoniae is a leading cause of
Rotavirus
severe pneumonia, especially in the
developing world2
Hib
•According to the 2015 estimates,
Hib and S pneumoniae were
Pertussis
responsible for close to 65% of
deaths due to lower respiratory
Measles
infections1
Neonatal tetanus

0 250.000 500.000

Penyakit pneumokokus masih menjadi masalah

kesehatan serius pada anak di dunia
Wang H, et al. Lancet. 2016;388(10053):1459-1544. 2. UNICEF/WHO. Pneumonia: the forgotten killer of children. 19
http://www.childinfo.org/files/Pneumonia
 Haemophilus influenzae
A Gram-negative coccobacillus that commonly
infects the upper respiratory track of children

The polysaccharide, is the primary factor

associated with virulence.

Of the 6 capsular types of H influenzae, type b

(Hib) is responsible for more than 90% of
systemic infections.

Carriage rates in children <5 years varied

H. influenzae on a blood agar plate
considerably from very low, e.g. 0.6%–1.3% in
Taiwan and Hong Kong, to 6%–8% in India and
Thailand.

https://www.who.int/biologicals/areas/vaccines/haemophilus/haemophilus_influenzae_typeb_Hib/en/ 2. Haemophilus influenzae type b (Hib) Vaccination

Position Paper – September 2013. Weekly epidemiological record 2013;88(39):413-28 20
 Streptococcus pneumoniae
• Bakteri Gram Positif1
• Kapsul Polisakarida1,2
– Faktor Virulensi
– Serotype
– Target Vaksin
• Ada lebih dari 90 serotype1,2
Streptococcus sp. Chains of nearly-spherical bacteria. From The Rockefeller University.
– Belasan serotype berperan
dalam 70% - 93% kasus IPD
secara global3
– Patogen yang biasanya
teradapat di nasofaring1

1. CDC. Epidemiology and prevention of vaccine-preventable diseases. 11th ed. 2009;217-230.

2. WHO. Acute respiratory infections (update September 2009). http://www.who.int/vaccine_research/diseases/ari/en/print.html. Accessed March 16, 2010.
3. Hausdorff WP et al. Clin Infect Dis. 2000;30(1):100-121.
4. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine Preventable Diseases. The Pink Book. 11th Edition. May 2009. 21
 Kolonisasi Nasofaring
• Nasofaring manusia merupakan tempat tinggal
pneumokokus  berfungsi sebagai reservoir dan sumber
transmisi pneumokokus antar individu.
• Pneumokokus yang tinggal menyebar dari nasofaring ke
jaringan sekitar (otitis media akut, sinusitis) atau menginvasi
pembuluh darah (pneumonia, bakteremia, meningitis)
OMA
Sinusitis Menyebar ke Individu Lain
 melalui droplet,
 Inkubasi 1-3 hari,
Pneumonia periode infeksius selama
Bakteremia organisme ada di sekret
pernafasan
ISPA sebagai predisposisi
Meningitis
CDC - Redbook online 2012

Image adapted from: http://www.1911encyclopedia.org/images/f/f4/Olfactorysystem-2.jpg.

1. Hull MW, et al. Infect Dis Clin North Am. 2007;21:265-282. 3. Regev-Yochay G, et al. Clin Infect Dis. 2004;38:632-639.
2. Cardozo DM, et al. Braz J Infect Dis. 2006;10:293-303. 4.Chi DH, et al. Am J Rhinol. 2003;17:209-214.
 Karier Nasofaring di Asia

Karier
Nasofaring di
Asia berkisar
9.0 % – 43.2 %

Carriage rate of pneumococci among children from 11 countries.

Lee NY, Song J-H, Kim S, et al, Carriage of Antibiotic-Resistant Pneumococci among Asian Children: A Multinational Surveillance by the ANSORP
CID 2001;32:1463-69
 Distribusi Serotipe Pada Pasien dengan
Pneumonia yang Disebabkan Pneumokokus
Gentile et al. Bender et al. Resti et al. Bewick et al. Cilloniz et al.
Serotypes (62) (63) (64) (66) (60)
Prospective Prospective
Retrospective Observational
Desain Study Meta-analysis Observational Observational
Study Study
Study Study

Periode Study (Thn) 1980–2008 1997–2006 2007–2009 2008–2010 2006–2009

Latin America
Wilayah Study US Italy UK Spain
and Caribbean
Adult (Age Not
Usia Populasi Study <5 Yr <18 Yr 0–16 Yr ≥16 Yr
Specified)
Jenis Pneumonia CAP Pneumonia Bacteremic CAP CAP Invasive CAP

Serotypes 14 (33.0%) 1 (22.6%) 1 (32.5%) 14 (18.6%) 1 (32.1%)

1 (11.0%) 3 (11.3%) 19A (15.0%) 1 (16.5%) 19A (17.9%)

5 (10.8%) 19A (10.5%) 3 (12.5%) 8 (14.5) 7F (6.0%)

6B (7.4%) 14 (5.6%) 5 (6.2%) 3 (8.3) 14 (6.0%)

15C (5.2%) 6B (4.8%) 19F (6.2%) 19A (8.3) 5 (4.8%)

19A (4.7%) 19F (4.8%) 14 (3.8%) 4 (1.7%) 4 (3.6%)

Song JY, Nahm MH, Moseley MA. Clinical Implications of Pneumococcal Serotypes: Invasive Disease Potential, Clinical Presentations,
and Antibiotic Resistance. J Korean Med Sci 2013; 28: 4-15.
 Karier Nasofaring pada Anak dengan HIV,
Jakarta
Serotype Jumlah %
19F 8 19
19A 4 10
6A/B 4 10
23F 3 7
11A 2 5
9V 2 5
sg18 2 5 PCV13 coverage:
12F 1 2
15B/C 1 2 60%
3 1 2
35B 1 2
35F 1 2
7F 1 2
Untypeable cps-positive 5 12
Untypeable cps-negative 6 14

Distribusi serotype dan coverage vaksin pada 42 S.pneumoniae

Isolat karier S.pneumonia anak terinfeksi HIV di Jakarta
Safari D, Kurniati N, Waslia L, et al. Serotype Distribution and Antibiotic Susceptibility of Streptococcus pneumoniae Strains Carried by Children Infected
with Human Immunodeficiency Virus. Plos One. 2014;9(10):1-7
 Karier Nasofaring pada Balita, Lombok
Serotype Jumlah Isolat % Isolat
6A/B 120 22 • Pada 1,200 anak sehat usia 2
19F 64 11 bulan – 5 tahun di Lombok
Tengah
23F 58 10

15 B/C 45 8
• Karier S. pneumoniae 46%

19A 24 4 • PCV13 coverage 56%

14 20 4

11A 19 3

10A 13 2

35B 10 2

18 9 2

Others* 60 11

Untypable 115 21
* Serotype (number): 34 (7); 22F (7); 35F (7); 15A (6); 3 (5); 20 (4); 31 (4); 38 (4); 4 (3); 17F (3); 7F (3); 1 (2); 12F (2); 33F (1); 7C (1); 9V (1).
Hadinegoro SR, Prayitno A, Khoeri MM, et al. Nasopharyngeal carriage of Streptococcus pneumoniae in healthy children under
five years old in Central Lombok Regency, Indonesia. Southeast Asian J Trop Med Public Health 2016;47(3):485-493
 Gunungkidul and Sumba Barat Daya
(Eijkman Institute, US CDC Jakarta, US CDC Atlanta, FKUI)
Studi cross sectional dengan sample minimum:
432 anak <1 tahun dan 986 anak 1-<5 tahun
Karier Nasofaring S.pneumoniae overall: 55%
• Gunungkidul: 31.2%
• N=188. Distribusi serotype: 6A/6B, 19F, 3, 14, 23F,
6C/6D, 15B/15C, 34
• Sumba Barat Daya: 84.5%
• N=364. Distribusi serotype: 6A/6B, 19F, 23F, 19A, 14,
11A/11D, 21
PCV13 coverage >50%
Safari D, Daningrat WOD, Khoeri M, et al. Risk Factors of Pneumococcal Carriage in Children Under 5 Years of Age in Indonesia. Poster No.198 ISPPD 11 th.
April 2018, Melbourne
 Karier Nasofaring pada Bayi, Bandung (1/2)
Universitas Padjajaran, Murdoch Children’s Research Institute, The University of Melbourne,
London School of Hygiene and Tropical Medicine, PATH

• 200 bayi sehat belum pernah divaksin PCV usia 8 • Total 1575 swab dikumpulkan. Ditemukan 314 episode
dan 12 minggu pada Visit 1: 98 bayi dari perkotaan karier. Prevalensi karier nasofaring meningkat sesuai
(Puter) dan 102 dari pedesaan (Jaya Mekar) umur dalam tahun pertama kehidupan

Karier 21.5% pada Enrollment 2 Bulan 

67.3% pada 12 Bulan. Pedesaan > Perkotaan
Prevalensi Karier Pneumokokus berdasarkan Umur pada Bayi yang Tinggal di Perkotaan dan
Pedesaan

Murad C, Dunne, E, Sudigdoadi S, et al. Nasopharyngeal carriage, serotype distribution and antimicrobial resistance genes of Streptococcus
pneumoniae among healthy infant in Indonesia during first years of life. Poster presented in ISPPD 11 th, Melbourne 15-19 April 2018
 Karier Nasofaring pada Bayi, Bandung (2/2)
Universitas Padjajaran, Murdoch Children’s Research Institute, The University of Melbourne,
London School of Hygiene and Tropical Medicine, PATH

Distribusi Serotipe pada Bayi Sehat

3 19A 6A

Murad C, Dunne, E, Sudigdoadi S, et al. Nasopharyngeal carriage, serotype distribution and antimicrobial resistance genes of Streptococcus
pneumoniae among healthy infant in Indonesia during first years of life. Poster presented in ISPPD 11 th, Melbourne 15-19 April 2018
 Deteksi Gen Resistensi Antibiotik
Universitas Padjajaran, Murdoch Children’s Research Institute, The University of Melbourne,
London School of Hygiene and Tropical Medicine, PATH

Deteksi Gen Resistensi Antibiotik (AMR gene) dengan Microarray

pada Sample yang mengandung Serotype Pneumokokus Tunggal
(N=478)

Murad C, Dunne, E, Sudigdoadi S, et al. Nasopharyngeal carriage, serotype distribution and antimicrobial resistance genes of Streptococcus
pneumoniae among healthy infant in Indonesia during first years of life. Poster presented in ISPPD 11 th, Melbourne 15-19 April 2018
Karier Nasofaring di Padang, Bandung, Lombok
Universitas Padjajaran, Universitas Andalas, Universitas Mataram, Murdoch Children’s
Research Institute, The University of Melbourne, London School of Hygiene and Tropical
Medicine, PATH
Studi cross sectional dengan sample 302 anak sehat usia 12-24 bulan

Karier Nasofaring overall:

• S.pneumoniae: 49.5%
• H.influenzae: 27.5%
• M.Catarrhalis 42.7%
• S.aureus: 7.3%

Dunne EM, Murad C, Sudigdoadi S, et al. OneCarriage of Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus
aureus in Indonesian children: A cross-sectional study. Plos One 2018;13(4): e0195098.
Karier Nasofaring di Padang, Bandung, Lombok
Universitas Padjajaran, Universitas Andalas, Universitas Mataram, Murdoch Children’s
Research Institute, The University of Melbourne, London School of Hygiene and Tropical
Medicine, PATH
20 serotype tersering yang diidentifikasi dalam swab nasofaring pada anak
Indonesia usia 12-24 bulan, berdasarkan area

Cakupan Serotype
PCV13:
Bandung 26/73 (36%)
Lombok 28/53 (53%)
Padang 22/38 (58%)

Dunne EM, Murad C, Sudigdoadi S, et al. OneCarriage of Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus
aureus in Indonesian children: A cross-sectional study. Plos One 2018;13(4): e0195098.
 20

Karier Nasofaring Pneumokokus di Indonesia

Ringkasan

Provinsi Tahun Subyek N paling%sering

Serotype positif
Lombok 1 1997 Anak, 0-25 bulan 6, 23,484
15, 33, 12, 19 48
Bandung 2 2002-3 Anak, 2 – 59 bulan 6B, 19F,
101223F, 14 60
Bandung 3 2004 Anak, 0-8 minggu 19F, 14,
1236B, 6C 11.4
Semarang4 2010 Anak, 6-60 bulan 6A/B,243
15 B/C, 11A, 23F,19F
43
Lombok5 2012 Anak, 2-60 bulan 1200
6A/B, 46
19F, 23F, 15 B/C,19A
Jakarta6 2012 Anak (HIV) 4-144 bulan 19F, 19A,
90 6A/B, 23F,46
11A
Gunung 2017 Anak, <5 tahun 1008
6A/6B, 31.2
19F, 3, 14, 23F
Kidul7
Sumba7 2017 Anak, <5 years 6A/6B,
81419F, 23F, 19A,
84.514

Karier nasofaring pada balita, pada umumnya sekitar 46% (31.2%-84.5%)

1. Soewignjo S, Gessner BD, Sutanto A, et al. Streptococcus pneumoniae Nasopharyngeal Carriage Prevalence, Serotype Distribution, and Resistance Patterns among Children on Lombok Island, Indonesia. CID. 2001;32:1039-
43 2. Murad C, Agustian D, de Gouveia L, et al. Serotype Distribution and Antimicrobial Resistance of Nasopharyngeal Pneumococci Among Children < 5 years with Non-Severe Pneumonia in Bandung, Indonesia, 2002-2003.
Abstract WSPID 2009 3.Kartasasmita CB, Murad C, de Gouveia L, et al. Nasopharyngeal Carriage of Streptococcus pneumoniae in Indonesia: Neonatal Acquisition and Intrafamilial Transmission Bandung, Indonesia, 2006 4.
Farida H, Severin JA, Gasem MH, et al. Nasopharyngeal Carriage of Streptococcus pneumonia in Pneumonia-Prone Age Groups in Semarang, Java Island, Indonesia. Plos One. 2014: 9(1):1-3 5. Hadinegoro SR, Prayitno A,
Khoeri MM, et al. Nasopharyngeal carriage of Streptococcus pneumoniae in healthy children under five years old in Central Lombok Regency, Indonesia. Southeast Asian J Trop Med Public Health 2016;47(3):485-493 6.Safari
D, Kurniati N, Waslia L, et al. Serotype Distribution and Antibiotic Susceptibility of Streptococcus pneumoniae Strains Carried by Children Infected with Human Immunodeficiency Virus. Plos One. 2014;9(10):1-7 7.Safari D, 33
Daningrat WOD, Khoeri M, et al. Risk Factors of Pneumococcal Carriage in Children Under 5 Years of Age in Indonesia. Poster No.198 ISPPD 11th. April 2018, Melbourne
 Argentina, PCV 2+1

Perawatan RS karena Pneumonia Pneumokokus pada Balita

Perawatan RS karena
Perawatan RS Pneumonia Pneumokokus* Pneumonia Pneumokokus+Empiema†

~72% ~64%
20,
11.8 reduction 16, reduction
10.9
(per 10,000 admissions)

(95% CI 8.4–15.9)
Hospitalization rates

(95% CI 7.2–14.5)
16,
12,
12,
8, 3.9
3.3
8, (95% CI 1.6–6.2)
(95% CI 1.6–5.9)
4,
4,

0, 0,
Pre-PCV Post-PCV Pre-PCV Post-PCV

The pre-PCV period was 2009–2011; the post-PCV period was 2012–2013.

Perawatan RS Pneumonia Pneumokokus menurun ~72% setelah

program imunisasi PCV. Perawatan RS karena Pneumonia
Pneumokokus + Empiema menurun ~64% pada periode yang sama
*P-CAP was pneumococcal CAP confirmed by positive blood culture.
†P-PD was pneumococcal pulmonary disease defined as P-CAP plus pneumococcal empyema.

IPD refers to PE, P-CAP, meningitis, bacteremia, peritonitis, arthritis, cellulitis and other.
CAP=community-acquired pneumonia; CI=confidence interval; PE=pneumococcal empyema; P-CAP= pneumococcal community-acquired pneumonia; P-PD=pneumococcal pulmonary disease
(P-CAP+PE). 34
López EL, et al. J Pediatric Infect Dis Soc. 2017; doi: 10.1093/jpids/piw089.
Efek Pneumococcal Conjugate Vaccine

• Penurunan penyakit pneumokok invasif

• Penurunan Nasal Carriage
• Imunitas HERD pada populasi yang tidak
diimunisasi
• Penurunan insidens resistensi antibiotik
Vaksin Pneumokokus, Bagaimana Bila Anak
Baru Datang Di Usia > 1 Tahun ?

Usia Dosis

7–11 3 kali, 4–8 minggu jarak antar dosis, dosis ketiga setelah usia 1
Bulan tahun, atau minimal 2 bulan setelah dosis kedua

12–23 2 kali, minimal diberikan 2 bulan setelah dosis pertama

Bulan

>24 Tidak Ada

1 kali, Kata
dapat Terlambat
diberikan hingga usia 5 tahun
Bulan Berikan Imunisasi PCV semasa Balita

1. http://www.idai.or.id/artikel/klinik/imunisasi/jadwal-imunisasi-2017 2. Latest BPOM Approved PCV13 Local Product Document. 2017

TREAT
Deteksi dini Pneumonia (WHO)

HITUNG FREKUENSI NAPAS !!

Napas cepat (tachypnea)

Batasan frek napas
Umur frekuensi nafas
< 2 bulan 60
2 - 12 bulan 50
1 - 5 tahun 40

Chest Indrawing
(tarikan dinding dada ke dalam)
Obati !!!!!!
• Setiap kader kesehatan dan petugas kesehatan mampu
melakukan Manajemen Terpadu Balita Sakit (MTBS).
• Diagnosis dini dan tepat oleh dokter.

• Pemberian antibiotik pada anak dengan gejala pneumonia,

seperti amoksisilin , mencegah kematian hanya 5000 rupiah.

• Pemberian oksigen dan rujuk segera ke fasilitas kesehatan bila

gejala pneumonia berat.

• Kesadaran masyarakat akan pneumonia.

KESIMPULAN
• Pneumonia merupakan penyebab kematian utama
balita di dunia termasuk di Indonesia
• Vaksinasi terkait pneumonia berperan menurunkan
angka kematian balita dan beban penyakit pneumonia
dan beban resistensi antibiotik
• Orang tua, kader, mahasiswa, pemuka masyarakat dan
petugas / tenaga medis berperan dalam pencegahan
dan penanggulangan pneumonia
• Pencegahan, deteksi dini dan pengobatan yang tepat
dapat menurunkan kematian akibat pneumonia
TERIMA KASIH