PERAN DOKTER KELUARGA

PADA KASUS COVID-19

MODUL TANGGAP PANDEMI COVID-19

FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA

 • Modul Pencegahan dan Pengendalian Infeksi Covid-19 Di Luar
RS dengan Pendekatan Kedokteran Keeluarga (KIKKI 2020)
RUJUKAN • Protokol Tatalaksana Covid-19, Edisi 1, 2020 (PDPI, PERKI,
PAPDI, PERDATIN, IDAI)
• Protokol Covid-19, April 2020 (PDPI)
MODUL KHUSUS
PENCEGAHAN & PENGENDALIAN INFEKSI COVID-19
DI LUAR RS DENGAN PENDEKATAN
KEDOKTERAN KELUARGA
• Keputusan Menteri Kesehatan Republik Indonesia No.
HK.01.07/MENKES/413/2020 tentang Pedoman Pencegahan
KOLEGIUM
GUGUS TUGAS PERCEPATAN PENANGANAN COVID-19 1 PEDOMAN PENCEGAHAN DAN PENGENDALIAN
1

dan Pengendalian Covid-19

CORONAVIRUS DISEASE (COVID-19) REVISI KE-4

ILMU KEDOKTERAN KELUARGA LAYANAN PRIMER

2020

PERHIMPUNAN DOKTER PARU INDONESIA

• Pedoman Penanganan Cepat Medis dan Kesehatan Masyarakat

Covid-19 Indonesi, Maret 2020 (Gugus Tugas Percepatan
leaflet Penanganan Covid-19)
Articles
• Family Oriented in Primary Care, 2013 (Susan Mc. Daniel)
leaflet

• Berbagai Artikel
Clinical course and risk factors for mortality of adult
inpatients with COVID-19 in Wuhan, China: a retrospective
cohort study
Fei Zhou*, Ting Yu*, Ronghui Du*, Guohui Fan*, Ying Liu*, Zhibo Liu*, Jie Xiang*, Yeming Wang, Bin Song, Xiaoying Gu, Lulu Guan, Yuan Wei,
Hui Li, Xudong Wu, Jiuyang Xu, Shengjin Tu, Yi Zhang, Hua Chen, Bin Cao

Summary
Lancet 2020; 395: 1054–62 Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019
Published Online (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and
March 9, 2020 clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed
https://doi.org/10.1016/
clinical course of illness, including viral shedding, have not been well described.
S0140-6736(20)30566-3
See Comment page 1014
Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-
This online publication has been
corrected. The corrected version
confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been
first appeared at thelancet.com discharged or had diedWhyby Do
JanWe
31, Need
2020. Antibody
Demographic,
Tests clinical, treatment,and
for COVID-19 and How
laboratory data, including
to Interpret serial
Test Results
on March 12, 2020 samples for viral RNA detection, were extracted from electronic medical records and compared between survivors
*Contributed equally and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors
Why Do We Need Antibody Tests for COVID-19?
Department of Pulmonary and associated with in-hospital death.viral infections currently relies on two major methodologies: Reverse Transcription
Diagnosing
Critical Care Medicine, Center of
Quantitative Polymerase Chain Reaction (RT-qPCR) and serological immunoassays that detect viral-
Respiratory Medicine, National
Findings 191 patients (135 from
specific Jinyintan
antibodies Hospital
(IgM and IgG)and
or 56 from Wuhan Pulmonary Hospital) were included in this
antigens.
Clinical Research Center for
Respiratory Diseases, Institute study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension
being the most common Although, RT-qPCR
(58 [30%] is a highly
patients), sensitive
followed test for SARS-CoV-2
by diabetes (the virusand
(36 [19%] patients) thatcoronary
causes COVID-19) it has
heart disease
of Respiratory Medicine,
PENDAHULUAN

• Tujuan pelayanan kesehatan adalah untuk

mempromosikan dan mempertahankan
kesehatan, mengembalikan kesehatan setelah
terjadinya sakit, dan meminimalisasi
penderitaan/komplikasi akibat sakitnya.
• Seluruh tujuan pelayanan tersebut ada di
PENCEGAHAN (primer, sekunder, tersier)
 Host
Agent

TRIAS Enviro
nment
EPIDEMIOLOGI

DISEASE
NATURAL HISTORY OF DISEASE

Sudah
bergejala Komplikasi
lanjut

Sembuh
Belum bergejala, sudah ada
perubahan dalam tubuh
35
Why Do We Need Antibody Test for Covid-19 and How to Interpret
Test Results, Diazyme Laboratories, 2020
Figure 1: Variation of the Levels of SARS-CoV-2 RNA and Antigen, IgM and IgG after infection.
 Survivors

Fever
Cough
Dyspnoea
ICU admission
Systematic corticosteroid
SARS-CoV-2 RNA positive
Days after illness onset Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 Day 15 Day 16 Day 17 Day 18 Day 19 Day 20 Day 21 Day 22

Sepsis ARDS Discharged

Non-survivors

Fever
Cough
Dyspnoea
ICU admission
Invasive ventilation
Systematic corticosteroid
SARS-CoV-2 RNA positive
Days after illness onset Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 Day 15 Day 16 Day 17 Day 18 Day 19 Day 20

Sepsis ARDS Death

Secondary infection
Zhou Fei, et all. Clinical Course and risk factors for mortality of adult inpatients with covid-19 in Acute kidney injury
Wuhan, China: a retrospective cohort study, Lancet 2020 Acute cardiac injury

Figure 1: Clinical courses of major symptoms and outcomes and duration of viral shedding from illness onset in patients hospitalised with COVID-19
Figure shows median duration of symptoms and onset of complications and outcomes. ICU=intensive care unit. SARS-CoV-2=severe acute respiratory syndrome coronavirus 2. ARDS=acute respiratory
distress syndrome. COVID-19=coronavirus disease 2019.

increase in differential expression of genes associated
with inflammation, whereas expression of type I inter-
feron beta was reduced.16 The age-dependent defects in
T-cell and B-cell function and the excess production of
type 2 cytokines could lead to a deficiency in control of in influenza and other respiratory viral infections.22–24 In
viral replication and more prolonged proinflammatory
responses, potentially leading to poor outcome.17
SOFA score is a good diagnostic marker for sepsis
and septic shock, and reflects the state and degree of
multi-organ dysfunction.18,19 Although bacterial infec-
tions are usually regarded as a leading cause of sepsis,
viral infection can also cause sepsis syndrome. Previ-
ously, we determined that sepsis occurred in nearly
40% of adults with community-acquired pneumonia due
to viral infection.20 In the current study, we found that found d-dimer greater than 1 µg/mL is associated with
more than half of patients developed sepsis. Additionally, fatal outcome of COVID-19. High levels of d-dimer have a
we found that more than 70% of patients had white
blood cell count below 10·0 × 10⁹ per L or procalcitonin
below 0·25 ng/mL, and no bacterial pathogens were
detected in these patients on admission. Sepsis was a
common complication, which might be directly caused
by SARS-CoV-2 infection, but further research is needed
Why Do We Need Antibody Test for Covid-19 and How to Interpret
to investigate the pathogenesis of sepsis in COVID-19
Test Results, Diazyme Laboratories, 2020
illness.
Figure 1: Variation of the Levels of
pneumonia include older age, pre-existing cardiovascular
diseases, and greater severity of pneumonia at presen-
tation.22 Coronary heart disease has also been found to be
associated with acute cardiac events and poor outcomes
this study, increased high-sensitivity cardiac troponin I
during hospitalisation was found in more than half of
those who died. The first autopsy of a 53-year-old woman
with chronic renal failure in Jinyintan Hospital showed
acute myocardial infarction (data not published; personal
communication with a pathologist from the Chinese
Academy of Science). About 90% of inpatients with
pneumonia had increased coagulation activity, marked by
increased d-dimer concentrations.25 In this study, we
reported association with 28-day mortality in patients
with infection or sepsis identified in the emergency
department.26 Contributory mechanisms include systemic
pro-inflammatory cytokine responses that are mediators
of atherosclerosis directly contributing to plaque rupture
through local inflammation, induction of procoagulant
factors, and haemodynamic changes, which predispose to
ischaemia and thrombosis.27–29
SARS-CoV-2 RNAIn addition,
and angiotensin
Antigen, IgM and IgG after infection.
How Should We Interpret IgM/IgG Serological Test Results?
The present IgM/IgG serological assay is designed to complement RT-qPCR in the diagnosis of SARS-
CoV-2 infections. Table 1 shows the clinical interpretation of all possible scenarios that can be
Why Do We Need Antibody Test for Covid-19 and How to Interpret
encountered when testing a patient with both RT-qPCR and an IgM/IgG serological test.
Test Results, Diazyme Laboratories, 2020 Figure 1: Variation of the Levels of SARS-CoV-2 RNA and Antigen, IgM and IgG after infection.

References:

1. Weaver, C. Questions About Accuracy of Coronavirus Tests Sow Worry. The Wall Street Journal.
April 2nd, 2020. Retrieved from https://www.wsj.com/articles/questions-about-accuracy-of-coronavirus-
tests-sow-worry-11585836001
(OTG)
2. Li R, Pei S, Chen B, Song Y, Zhang T, Yang W, Shaman J2. Substantial undocumented infection
facilitates the rapid dissemination of novel coronavirus (SARS-CoV2). Science. 2020 Mar 16. pii:
eabb3221.

3. Lauer, S. et al., 2020. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From
Publicly Reported Confirmed Cases: Estimation and Application. Annals of Internal Medicine.

4. National Health Commission of the People’s Republic of China, New Coronavirus Pneumonia
Diagnosis and Treatment Program (Trial Version 7).

5. To KK, Tsang OT, Leung WS, Tam AR, Wu TC, Lung DC et al. (2020). Temporal profiles of viral load
in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-
CoV-2: an observational cohort study. Lancet Infect Dis. 2020 Mar 23. pii: S1473-3099(20)30196-1.

MK 244 Rev. A

©2020 Diazyme Laboratories, Inc. All rights reserved. | Legal | Contact

Table 1: Clinical Significance of an IgM/IgG Serological Test Result

- ***Isolasi di Fasilitas Khusus: pengawasan hanya dapat dilakukan oleh peserta dengan SIP yang
sama dengan faskes pasien.

Rekomendasi Setelah Ada Hasil

Kesiapan Keluarga Pemeriksaan Lab
Hasil Covid-19
Siap Tidak Siap Isolasi Komunikasi Risiko

PHBS dan Physical distancing

(edukasi online)
Terkonfirmasi Telekonsultasi
**Isolasi di
Covid (+) (+) Pengobatan sesuai ProtokolR.
Rumah
Telemedicine bila perlu.
Pengawasan
Pencatatan dan Laporan harian
PHBS dan Physical distancing
(edukasi online)
Terkonfirmasi Telekonsultasi
***Isolasi di
Covid (+) (+) Pengobatan sesuai ProtokolR.
Fasilitas Khusus
Telemedicine bila perlu.
Pengawasan
Pencatatan dan Laporan harian
PHBS dan Physical distancing
(edukasi online)
Telekonsultasi
Probable **Isolasi di
(+) Pengobatan sesuai ProtokolR.
Rumah
Telemedicine bila perlu.
Pengawasan
Pencatatan dan Laporan harian
PHBS dan Physical distancing
(edukasi online)
Telekonsultasi
Probable ***Isolasi di
(+) Pengobatan sesuai ProtokolR.
Fasilitas Khusus
Telemedicine bila perlu.
Pengawasan
Pencatatan dan Laporan harian
Catatan:
- ProtokolR = Tatalaksana Pasien Covid-19 Perhimpunan Dokter Paru Indonesia (PDPI)
KESIAPAN KELUARGA

• Adakah pelaku rawat?

• Ruangan isolasi diri?
• Pemenuhan logistic?
• Alat komunikasi?
• Kondisi rumah (ventilasi, sanitasi, lingkungan)
• Sumber daya sekitar
• Five Family Oriented Question
FIVE FAMILY • Apakah ada anggota keluarga lain yang memiliki
ORIENTED masalah kesehatan yang sama dengan pasien?

QUESTION • Menurut keluarga, apa yang menjadi penyebab masalah

kesehatan pasien dan bagaimana cara mengatasinya?
• Siapa di antara anggota keluarga yang paling
peduli/perhatian dengan masalah kesehatan pasien?
• Apakah ada perubahan lain di kehidupan
pasien/keluarga bersamaan dengan masalah kesehatan
pasien? Sebutkan
• Bagaimana keluarga atau teman/kerabat membantu
pasien dalam menyelesaikan masalah kesehatannya?

McDaniel S, Campbell T, Hepworth J, Lorenz A. Family-Oriented Primary Care. 3rd ed. Springer Publishing Company; 2013
PENGELOLAAN KO-MORBID/POPULASI KHUSUS

Diabetes Penyakit
Geriatri Autoimun STEMI
Mellitus Ginjal

Non-STEMI Hipertensi PPOK Tuberkulosis

PERAN INSTITUSI KESEHATAN
PUSKESMAS/KLINIK/FKTP

Komunikasi
Masyarakat (PHBS Pemantauan dan Pemeriksaan RDT
analisis kasus ILI, Surveilans OTG, dan pengambilan
dan Physical ODP, PDP
ISPA, Pneumonia spesimen PCR
Distancing)

Kerjasama ToMa Edukasi karantina Memonitor Komunikasi Risiko

dan lintas sektor di rumah keluarga Covid-19

Pelaporan
berjenjang
PRIMARY, SECONDARY, TERTIARY PREVENTION