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Asian Journal of Healthy and Science
p-ISSN: 2980-4302
e-ISSN: 2980-4310
Vol. 2 No. 12 December 2023
EPIDEMIOLOGICAL INVESTIGATION OF DIPHTHERIA
EXTRAORDINARY EVENTS (KLB) IN GILI KETAPANG VILLAGE,
PROBOLINGGO REGENCY IN 2022
Retno Ningsih, Arief Hargono, Antonius Ratgono, Kunigunda Albert Da
Universitas Airlangga. Indonesia
Email: retno.ningsih-2021@fkm.unair.ac.id
Abstract
Diphtheria infection is caused by a toxigenic strain of Corynebacterium diphtheriae
with humans as the only reservoir. Diphtheria attacks children under 10 years old
and is highly contagious, especially in susceptible populations. Diphtheria can cause
an outbreak although it can be prevented by immunization. In 2022, 3 cases of
diphtheria were reported in Gili Ketapang Village, Probolinggo Regency. Objective:
to describe the epidemiology of the outbreak and identify the risk factors for
countermeasures. Methods: This research is a descriptive study with an outbreak
investigation report design. Results: There were 3 cases of diphtheria within 7 months
(February-August 2022) in Gili Ketapang Village with a CFR of 100% and the
highest attack rate in the toddler age group (0-4 years) of 0.5%. There were 2 positive
contacts (close contacts of 2nd Case) who were asymptomatic. Transmission is
strongly suspected to be caused by the carrier. The identified risk factors were low
IDL coverage, limited health facilities and availability of ADS, sociodemographic
conditions, and population mobility at risk of diphtheria transmission. The problems
found were the absence of PMO in providing prophylaxis and ORI coverage was still
low and incomplete. Conclusions and suggestions: The diphtheria outbreak in Gili
Ketapang Village has been confirmed by the laboratory test. The increase in the
incidence and mortality from diphtheria is caused by multi factors. The government's
role in increasing immunization coverage, early warning through active case finding
surveillance, monitoring, and evaluation of obstacles in prevention is urgently
needed.
Keywords: diphteria, disease outbreaks, vaccination coverage, immunization
INTRODUCTION
Based on the Regulation of the Minister of Health No.82 of 2014, diphtheria is
one of the direct infectious diseases that can be prevented by immunization (PD3I)
and is one of the diseases that can cause extraordinary events (KLB) (Nurhalimah,
2020). Diphtheria is caused by the bacterium Corynebacterium diphtheriae strains of
toxygenation where the only one that acts as a reservoir is humans. Transmission
often occurs by droplets through the air from coughing or sneezing sufferers or objects
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contaminated by bacteria. C. diphtheriae has 4 types, namely gravis, intermedius,
mythic and belfanti. All biotypes can become toxicated and cause severity. When in
the body, bacteria secrete toxins (toxins), then absorbed in the blood and can cause
complications, especially the heart and nerves which can result in death (Control et
al., 2005) (Akbar et al., 2019). Therefore, if one diphtheria suspect is found, the
management is in accordance with the handling of extraordinary events (KLB)
(Akbar et al., 2019).
Based on WHO data, over a period of 10 years (2010-2020), the incidence of
diphtheria with the highest incidence rate was in 2019 as much as 3.4 per 1 million
total population (22,986 cases) worldwide and almost half of them (10,224 cases)
came from WHO South East Asian Region (WHO-SEAR) member countries.
Indonesia ranks second highest with 495 cases in 2019 (4.8% of total SEAR cases),
then the number of SEAR cases decreased to 4,002 cases in 2020 and Indonesia has
6.5% of the total SEAR cases, which is 259 cases (Gilder et al., 2022).
increase in Diphtheria cases in Indonesia occurred in 2016, namely 591 cases
from the previous 529 cases in 2015. Areas affected by diphtheria cases also
increased, from 89 districts/cities in 2015 to 100 districts/cities in 2016. In 2017, the
Ministry of Health announced diphtheria outbreaks in Indonesia, reported 954
clinically diagnosed cases of diphtheria and 44 deaths and spread across 142
districts/cities from 28 provinces. In 2018 there was an increase in diphtheria cases
in Indonesia, there were 1,386 reported cases with 29 deaths. Then the trend of
increasing diphtheria cases decreased drastically in 2019 to 2020 is at the lowest
incidence rate of diphtheria incidence in Indonesia in the last 10 years (0.96 per one
million population) (Kemenkes, 2021).
East Java Province is the province with the largest proportion of case
contributors almost every year. Diphtheria has spread throughout regencies/cities in
East Java, although not at the same time. As in 2018, of the total diphtheria cases in
Indonesia, 50% of cases came from East Java (695 cases) and only 1 in 38
regencies/cities did not record cases, namely Tulungagung Regency. In 2019, cases
decreased by almost 50% from the previous year (358 cases) and there were 5 districts
with no recorded cases. Diphtheria cases continued to decline in 2020 (94 cases) until
in 2021 only 45 cases were recorded in 18 districts/cities (Qomari, 2022).
Diphtheria cases in Probolinggo Regency were recorded nil during 2019-2021,
until in 2022, in February a diphtheria case was reported from Gili Ketapang Village,
Sumberasih District, Probolinggo Regency so that an Extraordinary Event (KLB) of
Diphtheria was determined in Gili Ketapang Village by the Regent of Probolinggo.
Then the diphtheria case occurred again in June (the 2nd case), and on August 21,
2022, the Probolinggo Regency Health Office again reported the 3rd diphtheria case
in Gili Ketapang Village (CFR = 100%) through the W1 report. Based on this, an
investigation of the Diphtheria Outbreak was carried out. The purpose of
epidemiological investigation is to obtain an epidemiological picture and the spread
of diphtheria in Gili Ketapang Village for countermeasures.
RESEARCH METHODS
This research is a descriptive study with a case report design from the KLB
investigation conducted jointly between the East Java Provincial Health Office,
Probolinggo Regency Health Office, Probolinggo Class II Port Health Office,
Sumberasih Health Center and the Airlangga University FETP Team. The
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investigation was conducted in Gili Ketapang Village, Sumberasih District,
Probolinggo Regency in September-October 2022. The activities carried out are
primary and secondary data collection. Primary data was obtained through home
visits based on contact history, neighbors and playmates to obtain risk factor data as
well as visits to the Gili Ketapang auxiliary health center for immunization data
collection and vaccine storage. Other secondary data collection is immunization
coverage data, geographical data and data on the number of residents of Gili
Ketapang village. The instruments used for data collection are the Diph-1 form which
contains information about the patient's identity, sick history, treatment history and
contact history, as well as an RCA form to see the immunization status around the
location of the case home.
To verify the diagnosis, clinical and laboratory examinations are carried out
with throat and/or nose swab sampling in cases and potential close contacts. The
case criteria used based on the 2018 Edition of the Diphtheria Surveillance and
Control Manual are laboratory confirmation cases, epidemiological relationship
confirmation cases, clinically compatible and discarded cases (Akbar et al., 2019).
Data analysis is carried out descriptively.
RESULTS AND DISCUSSION
Identification of Diphtheria Outbreak Cases
Table 1 Identification of diphtheria confirmation cases in Gili Ketapang Village
Name
(initials)
Sex (Age)
Address
Sick start
date
Symptom
Immunization
status
Lab results
Outcome
In
the
swab
Given
prophylaxis
case
Close
contact
Case 1
(SSB)
P 6 Year 10
Month
Dusus
Mardian
23/02/2022
• Fever
• Swollen
neck
• White
patches on
the mouth
DPT
immunization
1, 2 and 3
Kultur (+)
C.
Diphteriae
-
61
Die
10/03/2022
Case2
(MAF)
L
2 Year 7
Month
Dusun
Gozali
08/06/2022
• Fever
• Sprue
• Swallowing
pain
• crowded
Not immunized
Kultur (+)
C.
Diphteriae
10
21
Die
13/06/2022
Positive=2,
i.e. Brother
(P,13thn)
and His
Aunt
(P,43thn)
Case 3
(MN)
L
3 Year 10
Month
Dusun
Suro
19/08/2022
• Fever
• Swollen
neck
Not immunized
Culture (+)
C.
diphteriae
3
3
Die
21/08/2022
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Verification of Diagnosis Results
Based on the classification of diphtheria diagnosis, the three cases of diphtheria
in Gili Ketapang Village are laboratory confirmed cases. Case information as in
figure 1
Figure 1 Chronology of diphtheria cases
In February 2022, a case of Diphtheria from Probolinggo Regency was
reported in the Gili Ketapang Village area which was later determined to be a KLB.
Following the death of the first case on March 10, the local government of
Probolinggo Regency took a countermeasure policy to carry out ORI. However, the
ORI has not yet been completed, another diphtheria case was reported in June and
August 2022.
Identify the Source and Mode of Transmission
Based on the chronology of events, it is suspected that there is no
epidemiological relationship between the three cases. This is attributed to the
residences of the three cases located in different hamlets, so it is suspected that there
was no interaction between the three cases before.
The absence of an epidemiological relationship between the three cases is also
reinforced by the timing of events between cases. The time gap between cases appears
more than the time of transmission of the disease. In theory, the transmission period
of a case is 2-4 weeks after its incubation period. The distance from the emergence
of case 1 to the occurrence of case 2 is 4 months (15 weeks) and the emergence of
case 3 is 11 weeks from the occurrence of case 2. The time distance of emergence
from case 1 to case 2 and case 2 to case 3, has exceeded the period of transmission of
cases.
The possibility that can occur is transmission through carriers (carriers) located
in Gili Ketapang Village or carriers who interact with cases outside Gili Ketapang
Village. The possibility of transmission from carriers is very large considering that
Gili Ketapang Village is a densely populated village.
Close Contact Tracing and Handling
Based on the results of contact tracing, case 1 obtained as many as 62 people (7
people (10%) from family, 25 people (40%) from school friends and teachers, and 30
people (50%) from neighbors or relatives). From the results of close contact tracing
23
February
Case 1 →
feeling
feverish,
and
25
February
Taken to
Saleh
Hospital.
Weak
26
February
Reported
W1
27
8 Maret
Designate
d as KLB
by the
regent
10 Maret
8 Juny
Case 2 →
experien
cing
symptom
s of
10 Juni
The
condition
did not
improve
brought to
13 Juny
Did not
improve, was
taken to Saleh
Hospital. Weak
condition
19 August
Case 3 had
symptoms of
high fever, was
taken to Habib
at his brother's
21 August
Not getting
better, he was
taken to the
emergency room
of Wonolangan
April-Mei
Ori round
1 was
carried
out with
the target
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of case 1, no clinical symptoms were found leading to diphtheria disease so as a form
of prevention, all close contacts were given erythromycin prophylaxis at a dose of
250 mg in 4 doses for 7 days for children (schoolmates) and a dose of 4x500 mg /
day for 7 days for adults.
The results of contact tracing in case 2, as many as 21 relatives/families. In
contact case 2 a throat swab was performed on 10 close relatives due to the limitation
of the tool. From the swab results of 10 close contacts, 2 contacts tested positive for
C. Diphteriae bacterial culture, namely in Big Brother and Aunt from case 2. There
were no symptoms leading to diphtheria even though the swab result tested positive.
This is a difficult thing to accept and a reason for the family to refuse the
investigation. But as a form of prevention, all contacts of case 2 have been given
erythromycin prophylaxis according to the dosage.
Family contact tracing results from case 3 were performed only on the nuclear
family. Of the 3 contact cases, 3 were also swabed and the swab results tested negative
for the three close contacts.
By Age
The three cases of diphtheria in Gili Ketapang Village are the age group of
children under 7 years old, where the population group is a vulnerable group for
diphtheria disease. If divided into age groups, the highest attack rate is the toddler
age group (0-4 years) which is 0.5 per 100 population (2/374x100 population). And
the attack rate in the age group of 5-9 years is 0.2 per 100 population (1/637x100
population).
By Gender
Based on gender, 2 (67%) cases are male and 1 (33%) cases are female. In
addition, there were 2 positive close contacts of the female sex.
Based on Symptoms
Based on the symptoms experienced by the three cases. Here is the distribution
of symptoms
Figure 2 Distribution of Symptoms of Diphtheria Cases in Gili Ketapang Village
in 2022
All cases (100%) experienced symptoms of fever and swollen neck, but only 1
case (33%) had pseudomembrane and 1 case (33%) had swallowing pain.
Based on Immunization Status
Based on the results of epidemiological investigations (form diph-1) regarding
immunization status, as many as 2 (66.7%) cases have never been immunized.
0,0
100,0
33,3
66,7
33,3
100,0
0 20 40 60 80 100 120
stridor
pseudomembran
nyeri telan
Presentase (%)
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Figure 3 Distribution of Immunization Status of Diphtheria Cases in Gili
Ketapang Village in 2022
By Time
Analysis of diphtheria cases in Gili Ketapang Village by time can be seen in the
following figure.
Figure 4 Diphtheria Case Analysis based on the incubation period of Diphtheria
Outbreak in Gili Ketapang Village in 2022
The three cases of diphtheria in Gili Ketapang Village, in theory, do not have
an epidemiological relationship according to the time of occurrence. This can be seen
from the calculation of the incubation period of the next case not being in the
transmission period previous case. The longest transmission period of diphtheria
disease is 4 weeks from the onset of symptoms. So in case 2, the incubation period is
in the range of June 3, 2022, while the transmission period of case 1 ends on April 7,
2022. Likewise, case 3, the incubation period is in the range of August 14, but the
transmission period of case 2, according to the calculation of the longest transmission
period in theory ends on July 11, 2022.
33,3%
66,7%
Diimunisasi
Tidak diimunisasi
Immunized
Not immunized
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By Place
Figure 5
Location of diphtheria case distribution in Gili Ketapang Village
The three cases are spread across 3 hamlets, the first case is from Mardian
Hamlet, the second case is residing in Gozali Hamlet and the third case is domiciled
in Suro. There was no linkage in activity between the three previous cases.
Identify risk factors
a. Immunization Coverage
The target of routine immunization coverage of diphtheria, both basic and
advanced, is 95%. From IDL coverage data in Gili Ketapang Village in the last 5
years (2017-2021), those with coverage below the target are 2017 and 2021,
namely 89.9% in 2017 and 70.1% in 2021.
Figure 6 Achievement of Complete Basic Immunization Coverage (IDL) of Gili
Ketapang Village in 2017-2021
89,90%
95%
103,04%
112,80%
70,10%
0%
20%
40%
60%
80%
100%
120%
2017 2018 2019 2020 2021
presentase IDL
Cakupan IDL target
Case 1
P;7;Kultur(+)
Case 2
L;3;Kultur(+)
with 2
confirmed
contacts:
P;13; Kultur(+)
P;43;Kultur(+)
Case 3
L;3;Kultur(+)
toksigenik gravis
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Cold chain conditions and vaccine management
Based on cold chain observations, it is known that at the Gili Ketapang Village
Auxiliary Health Center, there is only 1 cold chain that can store ±15 boxes of
vaccines. Cold chains are in a functioning condition but less optimal because they
have been using for a long time. The cold chain is not a new procurement, but used
use from a pharmaceutical warehouse that was functioned in Gili Ketapang Village
in 2017. The midwife on duty always checks the temperature every day. Temperature
indicators still work. The temperature is monitored at 2-4ºC. Vaccine Vial Monitor
(VVM) indicates condition A, which means the vaccine is suitable for use. Cold chain
cleaning is carried out once a month.
Administration of Anti-Diphtheria Serum (ADS)
Of the 3 cases that occurred, only case 1 received ADS, while case 2 and case
3 had not had time to get ADS because the condition had decreased when taken to
the hospital. ADS is not available at the District level, so patients have to wait for
ADS from the province after getting confirmation from a team of Diphtheria experts.
This is an obstacle in handling cases in hospitals that are at risk of increased CFR.
Drug Monitoring (PMO)
The designated medication monitoring for the 85 close contacts were cadres
and community leaders, but the PMO was not given a medication monitoring form
that was supposed to be filled out daily for 7 days. This is a possibility of losing
control of the continuity of monitoring medication adherence.
Condition of Health Services and Health Workers
Gili Ketapang Village is the working area of the Sumberasih Health Center
which is a separate island, so the distance to the main health center is quite far. The
only basic health service in Gili Ketapang Village is an auxiliary health center. If
residents need advanced health services such as practicing doctors, clinics or
hospitals, they must leave the village in Probolinggo City (because the crossing port
is in the city area). Meanwhile, the health workers assigned to the Gili Ketapang
center are 4 midwives.
In terms of administration, Gili Ketapang Village is divided into 8 hamlets,
namely Coastal Hamlet, Mujahideen Hamlet, Krajan Hamlet, Baitur Rohman
Hamlet, Mardian Hamlet, Gozali Hamlet, Suro Hamlet and Marwa Hamlet. There
are 7 posyandu and 34 cadres to assist in Community Resourced Health Efforts
(UKBM) activities.
Socio-Demographic Conditions
The total population of Gili Ketapang Village in 2021 is 8,509 people (the result
of BPS projections for Probolinggo Regency) with an area of 0.61 km2 (1.9% of the
district area). The average population density is 13,949 inhabitants for each km2. The
population density is categorized as very dense. The residents of Gili Village are a
Madurese tribe with Madurese as a colloquial language.
The dominance of the population according to age is 30-49 years old which is
the population of productive age. Fishermen's livelihoods are the main livelihood in
Gili Ketapang Village. Based on data on the level of education of the population over
5 years, it is known that most of the population has a low level of education, namely
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45% do not go to school, 26% do not finish elementary school and 24% finish
elementary school. Only 2% completed high school and college education.
Population Mobility
The mobility of the residents of Gili Ketapang Village is quite high. This is
because the village is a separate island, so every day there is always traffic in and out
of the village to meet the needs. Every morning there is always a motorboat that
transports the residents of Gili Village to Probolinggo City for shopping and other
activities, as well as people who work on the island of Gili, such as teachers and other
officers who are always travelers.
Countermeasures carried out
a. Health Counseling
Health counseling and information submitted are symptoms that must be
watched out for, then advised to immediately inform health workers if they
experience or there are neighbors / relatives who have symptoms like those
suffered by the patient. Officers also provided information to the public about the
importance of immunization.
b. Administration of prophylactic therapy on case contacts
One of the efforts to prevent and cure diphtheria is to increase immunity in
people who have been in contact with sufferers. Prophylactic therapy is given to
all contacts that have been identified at the time of epidemiological investigation.
The therapy given is erythromycin at a dose of 50 mg / kgBB / day in 4 doses for
7 days.
c. Rapid Convenience Assesment (RCA)
This activity is carried out by recording the immunization status of toddlers
in Gili Ketapang Village around the case house of at least 20 houses. This activity
aims to validate the immunization coverage of toddlers in the region. The target
coverage is that 95% of toddlers have been given basic immunizations. RCA
results from 30 children, 17 children (56.7%) were under five years old (Toddlers)
and 13 children (43.3%) were five years old and above. The complete basic
immunization coverage for DPT-1-2-3 is 70%. The value is still below the
supposed target.
d. Outbreak Respon Immunization (ORI)
After the establishment of the Diphtheria Klb in Gili Ketapang Village in
March 2022, the implementation of the first round of ORI carried out in April-
May has not yet reached the target target. The implementation of the first round
of ORI until May is still below 70%, and due to these low achievements, the
immunization status of ORI case 2 and case 3 is still nil, especially since they have
not received basic DPT immunization at all. Finally, the implementation of the
first round of ORI was accelerated and continued the 2nd round of ORI. Finally
in August, the first round of ORI has reached 98.8% and the implementation of
the 2nd round of ORI is 70%. The pursuit of the ORI 2 target will continue until
the implementation of ORI 3 which starts in October until it is completed.
e. Verification of Diphtheria KLB Cases
There have been 3 cases of diphtheria in Gili Ketapang Village from
February to August 2022. Based on the operational definition of diphtheria
diagnosis, all three cases are laboratory confirmed cases. The symptoms
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experienced by all cases are fever and bullneck, but only 1 case experienced the
typical symptoms of diphtheria, namely the presence of pseudomembrane. The
local government issued a decree establishing klb in Gili Ketapang Village after
the first case was found in February. This is in accordance with the operational
definition of klb determination which states if in a district / city area one
diphtheria suspect is found with the confirmation of a positive culture laboratory
is a diphtheria outbreak (Akbar et al., 2019).
The KLB can be determined by the head of the district/city health office, the
head of the provincial health office or the minister of health. The determination of
the diphtheria klb of Gili Ketapang Village is determined through the Decree of
the Regent of Probolinggo No. 440/154/426.32/2022. This is expected to
encourage more serious handling efforts because it involves the highest leadership
in a region. It is associated with the support of operationalization of activities. In
its operations, countermeasures are always accompanied by investigations, and
their implementation requires preparation of both logistics, human resources and
comprehensive cross-program cooperation (Akbar et al., 2019). So that it will be
easier if you get direct support from regional leaders.
f. Identify the Source and Method of Transmission
Based on descriptive epidemiological analysis, there is no epidemiological
relationship between the three cases in terms of chronology and time of
occurrence, because the estimated incubation period of each case has passed the
previous case transmission period if the first case (SSB) is considered an index
case. Likewise, in terms of place, even though they are located in one village, the
three of them never interact because they are in different hamlets and have no
relative relationships. The source and method of diphtheria transmission in Gili
Ketapang Village is strongly suspected to come from carriers. In endemic areas,
3%-5% of people who do not show symptoms can act as carriers or carriers of
thixoxygenated diphtheria bacteria. C. Diphteriae bacteria can survive in the
outside air for up to 6 months (Hartoyo, 2018). In line with the epidemiological
investigation at the Diphtheria Outbreak in Ngawi in 2015, the transmission of
cases by proximity to the location has not found strong epidemiological evidence,
but from the analysis of the transmission period from the incubation period the
cases are likely to be more likely to be infected by the carrier (Rahman et al., 2017).
g. Close Contact Tracing and Handling
To control the spread of the disease and preventive efforts to prevent the
spread of transmission, close contact tracing is carried out. 85 close contacts of all
three cases have been identified. All contacts had been given erythromycin
prophylaxis according to dosage and 13 close contacts were taken throat swabs.
Positive C. Diphteriae bacterial culture results were found from 2 close contacts
of the second case (MAF) although both were asymptomatic. Both contacts can
be a career and a source of contagion for their environment. A diphtheria carrier
is a person who has a toxygenic diphtheria germ and can transmit it even if it does
not cause upper respiratory symptoms (pharyngitis or laryngitis) or other systemic
symptoms (Cdc, 1993).Therefore, any close contact is given antibiotics to prevent
the proliferation of germs. With 3 cases of diphtheria with death and the discovery
of a positive contact with diphtheria shows the spread of the disease in Gili
Ketapang Village.
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In close contact management should also appoint a Drug Supervisor (PMO).
Close contact of diphtheria cases in Gili Ketapang Village has appointed a PMO,
but no monitoring or recording has been carried out, this is also a risk. Supervision
of taking medications should be carried out mainly on the 1st and 2nd days
because bacteria are estimated to die after administering antibiotics for two days,
as well as the 7th day so that there is no withdrawal of antibiotics that can cause
resistance. PMOs should come from health cadres or community leaders and not
come from families (Akbar et al., 2019).
h. Case Epidemiology
The three cases in diphtheria outbreak in Gili Ketapang Village are in the
age range of under 10 years. The largest attack rate of 0.5% is in the age range of
0-4 years. 67% of cases have not received a complete basic immunization. From
the results of close contact tracing, it was found that 2 positive close contacts were
female who were over 10 years old, namely 13 years old and 43 years old. The two
close contacts are strongly suspected to be carriers of diphtheria. Similar to other
studies in Samarinda City show that there are more female diphtheria carriers than
men (Pratama & Tandirogang, 2019). Several studies on susceptibility to
diphtheria in adults have also shown that seroprotection deficiency is more
common in women than men. This difference may be due to a gender-specific
immune response after vaccination (Sharma et al., 2019).
All diphtheria cases in Gili Ketapang Village have the last state of death
(CFR=100%). Apart from immunization factors, this is often attributed to delays
in handling that can be caused by the existence of distant health facilities. Gili
Ketapang Village is an island where there are only auxiliary health centers, so if
you need intensive treatment, you have to go to the hospital, which means you
have to cross the island to Probolinggo City. In line with the research on risk
factors for diphtheria events in Blitar Regency which states that access to health
services such as mileage to health care facilities is related to diphtheria events, long
distances allow delays in treatment that can aggravate the patient's condition
(Pratama & Tandirogang, 2019).
i. Risk Factor Identification
The cause of the increase in diphtheria cases or transmission is caused by
multi-factors. Of the immunization status of the three cases, only the first cases
received DPT immunization 1, 2 and 3, while cases 2 and 3 never received
immunization. From the complete basic immunization coverage data report of
Gili Ketapang village, immunization coverage is still below the target of 90%
achievement. Although diphtheria immunization is an effective effort to prevent
diphtheria disease, diphtheria can reappear due to low immunization coverage. In
line with the study of epidemiological characteristics and immunization status of
diphtheria patients in East Java, the completeness status of immunization plays a
very important role in the incidence of klb in 2018, especially patients who do not
have a complete immunization history and have never received immunization
(Wigrhadita, 2019).
Gili Ketapang Village only has one auxiliary health center with 4 midwives
on duty. This is not commensurate with the total population of Gili Ketapang
Village which reaches 8509 people. The reason is, in addition to carrying out
mandatory duties, village midwives also carry out puskesmas activities in the form
of public services in their work areas. The existence of village midwives is very
923
important in infant and child health services, in this case including the
implementation of basic immunization (Safitri, 2019). Vaccine monitoring should
be carried out more strictly because the coldchain used has a long service life.
Vaccines are very sensitive to heat and freezing temperatures, it is necessary to
periodically evaluate how the distribution pattern is because once the vaccine loses
its potency, it will not be able to be repaired and the vaccine will not provide the
protection as expected (Sariadji & Sembiring, 2019).
In the diphtheria surveillance manual, the provision of ADS logistical
support can be carried out at the provincial and district levels. However, ADS is
not available at the district level so in its need it needs to wait from the provincial
level. Treatment of diphtheria requires anti-diphtheria serum and antibiotics.
Serum and antibiotics are given together because serums cannot be used to kill the
causative bacteria and prevent disease transmission. Vice versa, antibiotics cannot
replace the role of serum to neutralize diphtheria toxin. Serum will be effective
when administered in the first three days from the onset of symptoms. Delays in
serum administration will increase the risk of complications and death (Control et
al., 2005) (Sariadji & Sembiring, 2019).
Gili Ketapang Village has a high population density compared to its area,
this also causes the density of housing and the distance between houses is very
close. The dense environment of residents facilitates the transmission of diphtheria
(Sariadji & Sembiring, 2019).The total population of Gili Ketapang Village is
dominated by the young adult age group. In addition to immunization factors, the
increasing adult population that is susceptible to disease can also increase the
incidence of diphtheria. This is in accordance with other studies that state the
body's anti-DT decreases with age due to changes in the immune system and/or
inadequate vaccination at an early age (Sharma et al., 2019). Therefore,
revaccination in adulthood is recommended to maintain herd immunity. The
majority of the education of the residents in Gili Ketapang village do not go to
school and do not finish elementary school. The level of education of parents
influences the knowledge and behavior of prevention as well as awareness to
provide immunization to the child (Putranto et al., n.d.).
The geographical condition of Gili Ketapang Village in the form of an island
triggers the high mobility of residents in and out of the island to meet their needs
due to the limited public facilities on the island. Population mobility is a factor to
watch out for because it increases the risk of spreading bacteria from one place to
another and increases contact from one person to another (Rahman et al., 2017).
j. Obstacles in Countermeasures
Efforts to overcome klb are carried out with the aim of breaking the chain of
transmission so as to reduce the number of pain, death and the area of the affected
area. After being designated as a KLB, efforts have been made such as counseling
related to diphtheria, symptoms, causes and prevention methods, close contact
tracing followed by the provision of prophylaxis according to guidelines. The
problem with the prophylactic administration is that there is no recording and
reporting from the appointed PMO. Then ORI was carried out on the total
population of Gili Ketapang Village. One of the provisions for the implementation
of ORI is to be carried out on the area of one regency/city but if it is not possible
for some reason, the ORI is carried out at least one sub-district with a target
according to epidemiological studies and is carried out as soon as possible with an
924
interval of 0-1-6 months (Akbar et al., 2019). Regional policy establishes ORI in
Gili Ketapang Village with a total population target in the hope of forming herd
immunity in villages on one island. However, in its implementation there are
obstacles, namely that it is not carried out immediately so that the initial
achievements are still very low. The implementation of the first ORI has not been
completed, until it appears next case. The next obstacle is a decrease in coverage
at the next implementation interval caused by several factors such as employment
reasons, illness and rejection. Incomplete implementation of ORI will cause an
immunity gap. Individual immunity is affected by the frequency of immunization
administration, while incomplete administration of the vaccine cannot form herd
immunity. This causes groups that do not follow the complete immunization to
have a greater potential to contract or transmit diphtheria in the future (Radian et
al., 2018).
CONCLUSION
There has been a Diphtheria Outbreak in Gili Ketapang Village, Probolinggo,
which has been confirmed positive by laboratory examination. There were 3 cases of
diphtheria within 7 months (February-August 2022) in Gili Ketapang Village with a
CFR of 100% and the largest Attack rate in the toddler age group (0-4 years) of 0.5%.
From the identification of close contacts, 2 positive contacts (close contacts of case
2) were found who had no symptoms. Based on the epidemiological picture,
transmission is strongly suspected to be caused by carriers, not direct transmission
between cases. Risk factors for diphtheria outbreaks in Gili Ketapang Village include
low basic immunization coverage or has not reached the target, limited health
facilities and resources, inefficient ADS management, sociodemographic conditions
and mobility of residents who are at risk of transmitting diphtheria disease. The
problem found in the countermeasures was that the administration of prophylaxis
was ineffective because there was no monitoring of drug adherence and constraints
on the slow achievement of ORI targets.
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Copyright holders:
Retno Ningsih, Arief Hargono, Antonius Ratgono, Kunigunda Albert Da (2023)
First publication right:
AJHS - Asian Journal of Healthy and Science
This article is licensed under a Creative Commons Attribution-ShareAlike 4.0
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