BRAINs IMSTC 2014

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Bundle Regular of AMSA-Indonesia National Competitions (BRAINs) is a full compilation of all works submitted in every national competitions held

by Asian Medical Students’ Association (AMSA) Indonesia. The previous bundle is named AMSA Indonesia National Competition Bundle (AINCB).

Each year, AMSA Indonesia held three national competition events entitled Pre-conference competition for East Asian Medical Students’ Conference (PCC for EAMSC), National Paper Poster Training, and also Pre-conference competition for Asian Medical Students’ Conference (PCC for AMSC).

This bundle compile all works participated in IMSTC 2014. The theme for this competition is “Indonesian Common Traveler Disease”.

In this competition, all members of AMSAIndonesia may send Scientific Papers, Scientific Posters, Public Posters, Public Videos, and Photos.

Once compiled, Bundle of AMSA will be both distributed to all local AMSA and published via the AMSA-Indonesia web so that all members could easily access and obtain useful information gather in this bundle.

Enjoy and keep involved in academics!

Regional Chairperson Garda Widhi Nurraga Universitas Diponegoro Secretary of Academics Fabianto Santoso Universitas Indonesia

A-Team AMSA-Indonesia

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Scientific Paper

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THE ROLE OF COMMUNITY PARTICIPATION IN DENGUE CONTROL RELATED TO TRAVELLER DISEASE IN INDONESIA Betharia Susi, Alexandria Stephanie Atma Jaya Catholic University, Indonesia Abstracts Background: Dengue disease is currently a major health problem in Indonesia that affects all provinces. Indonesia has annually experience approximately 100.000 reported cases of dengue fever and dengue hemorrhagic fever in recent year. (1) Material & Methods: This study is conducted by searching the worldwide websites, journals and articles associated to dengue infection in the world and in Indonesia, reviewing the second analysis from research resulting of prevalence of dengue infection in Indonesia, the barriers that increase dengue, and how to prevent and control dengue fever in Indonesia.

Results: The expansion of dengue is expected to increase due to factors such as the modern dynamics of climate change, globalization, travel, trade, socioeconomics, and emergence of vector resistance to insecticides, weak public health actions, and response to outbreaks, community ignorance settlement and also viral evolution. The disease has now spread from urban to rural areas in the develop country. The increased of number of dengue cases in returning travellers from Indonesia due to the epidemiology of dengue in the country.

Conclusions: A community based environmental management embedded in a routine control programme was effective at reducing levels of Aedes infestation. Adequate funds, technical and human capacity, cooperation between health centres (HC) and village networks, and strategies for overcoming adverse physical conditions, are all necessary for effective and efficient outreach.

Keywords: Dengue, community participation, traveller disease, Indonesia

Introduction Dengue is one of the most important arthropod-borne viral disease which large global burden, with up 40 % of the world population living in the endemic regions.

Among the travellers to tropical countries, dengue infection is increasingly reported, and it is now leading to cause of posttravel fever. (2) Outbreaks of DF were already described since the 18th century

by Benjamin Rush who described an epidemic of break-bone fever in Philadelphia in 1780. During the last halfcentury cases of severe DF have been increasingly recognized. (3) Epidemic DHF emerged in Southeast Asia following World War II. Nearly 72% of the global population at risk of dengue lives in the Asia Pacific.(4) The WHO South-East Asia Region is home for 1.8

billion people under threat of dengue in 10 of its 11 Member States. (5) The first recorded DHF epidemic in this area occurred in Manila, the Philippines, in 1953−1954, (6) one followed by another in 1956.

Dengue was first recognised in Surabaya and Jakarta in Indonesia in 1968 it is amount 58 cases with 24 deaths (CFR 41, 3%). (7) In Indonesia, cases caused by dengue virus seem to fluctuate but they tend to increase yearly. DHF peak monthly incidence is frequently reported during October through April, months which coincide with the rainy season. The peak of epidemic repeated every 9-10 year and becomes a public health problem annually while periodic major outbreaks occurred such as those in 1998, 2004, and 2010.(8) The worst dengue outbreak occurred in 2010 with more than 150.000 cases of DF

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which were reported by Ministry of Health of Indonesia, including more than 30.000 hospitalizations.(9) WHO reported that Indonesia is in the second country with the highest incidence since 2010 in the world after Brazil. (10) Since 2013, the morbidity rate for Indonesia ranged from 3.39 to 8.65 per 100,000 populations. Indonesia is one of the countries where dengue is hyperendemic and all our serotypes are known to circulate in at least 400-497 districts, with more than 200 million people at risk for dengue infection. (11) DF is become the major public health problem with an estimated 50-100 million annual cases worldwide and reported 250,000-500,000 cases every year, respectively. It has reported that more than 100 countries and continues to spread previously to unaffected regions. (3) The cumulative reported numbers of Dengue cases in 2012 showcase the devastating impact of dengue on human health around the world: 262,542 cases in western pacific regional 992,285 cases in America. In 2013, recent modelling global dengue burden estimated a total 390 million dengue infection annually. This is almost eight times larger than the WHO estimate of 50 million dengue infection annually, of which resulted of 1.5 million cases of DHF and DSS and a case fatality rate of 2.5 %. Furthermore, the economic cost of Dengue reported in America reached US$ 2, 1 billion per year. DF imposes a societal burden that is difficult to measure because of the disease’s nonspecific symptoms and the lack of easily applied definition for its more severe manifestations. (12) A clear picture of the Dengue global geographic expansion is of consequence, because vector controls remain as the main resource for disease containment, since the leading vaccine candidate was only 30 % effective in its first clinical trial. (13)

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Dengue disease is currently a major health problem in Indonesia and affects all provinces in the country mostly during and shortly after the rainy season.

Material and Methods The objective of this study is to overview the prevalence of dengue infection and to understand the important of dengue infection prevention and control in Indonesia as one of the common traveller disease.

This study is conducted by several major steps such as searching the worldwide websites, journals and articles associated to dengue infection in the world especially in Indonesia, reviewing the second analysis from research resulting of prevalence of dengue infection in Indonesia, barriers of factor increase determinant and how to prevent dengue infection in Indonesia.

Results Dengue fever in returned travellers (14-18) A study shows that increased travel to the Indonesian island has resulted in a rising number of serious diseases, such as DF. (14) More than half of all dengue cases with a known country of acquisition between 1999 and July 2012 were acquired in Indonesia. In Western Australia in 2010 and 2011, more than 80% of cases acquired in Indonesia were acquired in Bali and the trend has continued into 2012.

(15) While the frequency of travel by Australians to Indonesia has steadily increased since 2000, this does not completely explain the increased number of dengue cases in returning travellers. The relative risk of dengue in travellers returning from Indonesia between 2000 and 2011 compared with all other destinations was 8.3 (95% CI : 7.9–8.9).(14) Indonesia was the most frequently reported country of acquisition among overseas acquired cases of dengue in Australia

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between 1999 and July 2012, with overseas travel there accounting for 52% of cases with a known country of acquisition during those years. Most cases related to travel in Indonesia occurred between 2010 and July 2012 (1,834 cases).

More than half of all cases related to travel to Indonesia were from Western Australia 56%, and in 2010 and 2011, more than 80% of these were among travellers returning from Bali. This trend has continued into 2012, with 83% of cases between January and September 2012 in Western Australia associated with Indonesia, and of these, 96% reported travel to Bali.(15) Cases of dengue acquired in Indonesia are most frequently diagnosed between December and April, whilst the peak season of travel to Indonesia is between June and October 2012.

While the frequency of travel by Australians to Indonesia has steadily increased since 2000, this does not completely explain the increased number of dengue cases in returning travellers. The relative risk (RR) of dengue in travellers returning from Indonesia compared with all other destinations was 8.3 (95% CI: 7.9 - 8.9). The risk of a traveller acquiring dengue in Indonesia varies from year to year and appears to have increased overall from 2000 to 2011, and peaking in 2010.

Another study said that the vast majority of cases (83%) were associated with travel to Indonesia which the Indonesianacquired cases, 395 (96% overall) reported travel to Bali. Most of the infections were acquired in Bali. In the year ending June 2012, Indonesia (primarily Bali) was the most popular holiday destination (328,000 visits) for Western Australians (Australian Bureau of Statistics data). (14, 18) Table 1 shows characteristics of 447 shortterm travellers to sub-tropical areas in Asia and Indonesia as one of primary country visited in Asia.16

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Table 2 shows attack rates and incidence rate of seroconversions for DEN antibodies by primary destination in 447 Dutch travellers to Asia and Indonesia as one of the highest primary destination per months.16

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Table 3 shows demographic characteristic of the overall study cohort and Indonesia is the fifth country and Indonesia is the fifth country which is visited in days.17

Table 3. Demographic characteristics of the overall study cohort

Figure 1. Traveler days in destination countries from 2007 to 2010 : a.

South Asia, b. South East Asia, c. East Asia. The days travelled in individual countries in each region divided into quarters (Qtr 1: January-March; Qtr 2: April-June; Qtr3: July-September; Qtr 4: October- December) for the respective years.17

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Dengue cases in Indonesia The number of dengue fever cases in Indonesia has risen 14 per cent in the first semester of 2013 year on year. (11) In 2012, 90,245 cases (IR 37.1 per 100,000), 816 deaths (CFR 0.9). Male 53,2 % and female 46,8 % in 2013, CFR is decline but IR still increase. Figure 2 shows five provinces With Highest CFR: West Papua (CFR=11,11), Maluku(CFR=5,61),

.

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Gorontalo (CFR=2,36), Bangka-Belitung (CFR=2,33) and Jambi ( CFR=2,21).

Figure 3 shows five provinces with Highest Incidence: Central Sulawesi (IR=85,00), Bangka-Belitung (IR=84,95), East Kalimantan (IR=84,32), Lampung (IR=76,52) and Jakarta ( IR=68,84). (7)

Figure 2.

The highest province with case fatality rate of DF per 100.000 population in Indonesia since 2005-2009

Figure 3.

The highest five provinces with incidence rate of DF per 100.0000 population in Indonesia since 2005-2009

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Since 2005-2009, DKI Jakarta was one of provinces which had the highest incidence rate of DF (313 cases per 100.000 populations) while Nusa Tenggara Timor had the lowest incidence rate of DF (8 cases per 100.0000 populations). In 19931998, less than 15 years were susceptible due to low immunity but in 1999-2013 the risk factors were above 15 years old and visitors to Indonesia. (8) Jakarta, Java Island and Bali experience high number of cases due to high population density. Dengue incidence increases during and shortly after rainy season. All four serotypes of dengue virus have been found in Indonesia. Provinces with highest incidence rates do not necessarily have the highest CFR. Dengue incidence increase related to weather changes. (5,7) Discussion Dengue virus infection is an acute infectious mosquito-borne viral disease causes a spectrum of illness ranging from asymptomatic, mild undifferentiated fever to classic fever (DF), and dengue fever with haemorrhagic manifestation, or dengue haemorrhagic fever (DHF) and the dengue shock Syndrome (DSS). The disease is caused by dengue virus (DEV), a member of Flaviviridae family, with four distinct serotypes (DENV-1,-2, -3, -4)(19) circulating in tropical and subtropical areas of the world, where approximately 2.5 billion people at the risk. DENV is transmitted to human by Aedes mosquitoes as vector, with Female Aedes aegypti being the most important vector and Aedes albopictus the second vector. (20) DF can occur when a mosquito carrying the group B arbovirus bites a human, passing the virus on to the new host. Once in the body, the virus travels to various glands where it multiplies. The virus can then enter the bloodstream. The presence of the virus within the blood vessels, especially those feeding the skin, causes

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changes to these blood vessels. The vessels swell and leak. It present with high fever.

The spleen and lymph nodes become enlarged, and patches of liver tissue die. A process called disseminated intravascular coagulation (DIC) occurs, where chemicals responsible for clotting are used up and lead to a risk of severe bleeding (haemorrhage). (21,22) The process begins when a person who is infected with the Dengue virus is bitten by a mosquito; the virus is then passed on when someone else is then bitten by the infected mosquito. After the virus has been transmitted to the human host, a period of incubation occurs. During this time (lasting about five to eight days) the virus multiplies.(22) Factors increasing the risk of dengue infection Dengue infection increases in Indonesia as the results of population growth and urbanization, poor sanitation and hygiene, and an increased range of both virus and vector.

The main mosquito vector, Aedes aegypti, breeds in still, clear bodies of water and thrives in human-made receptacles such as discarded pots, tires, and water storage containers. In Indonesia, water from rain, rivers, wells, or other sources is stored for domestic use in large concrete water jars, and many studies have shown that these jars constitute over 80% of Aedes Aegypti larval habitats (21) In cities, the movement of infected persons is a more important means of transporting dengue viruses than the movement of Aedes aegypti mosquitoes. Places where people congregate during the day may be important sites of dengue virus transmission. Dengue virus may also spread in settings involving large numbers of people, such as in hospitals where visitors, patients and staff may be bitten by infected Aedes aegypti. Infected persons

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may carry dengue virus to towns and rural areas from cities where the disease is epidemic or endemic. Introduction of dengue virus by the air travel of infected passengers over long distances has repeatedly occurred in the Pacific region during the past 30 years. (2,23) While methods for vector control such as mosquito breeding source reduction and focal insecticide spraying that have been practiced to reduce dengue transmission in Indonesia have had limited success, dengue vaccines are expected to be an effective control method in the future though the right vaccine has not been found.(22) Environmental conditions in the rural or urban like in Jakarta are conducive to dengue transmission. Those who stay in slum area in Jakarta and work as scavengers who keep the empty bottles, others waste product, shells, plastic bags and other disposable items are indiscriminately discarded throughout the environment which providing ideal conditions for the breeding of the vector, Aedes mosquito; water jars are rarely covered and contain larvae year round; houses are built above the ground of wood, cartoon materials in slum area, bamboo and thatch in the rural area, and are in very poor condition, allowing easy access of the anthropophilic and endophilic vector.(11,12) The presence of discarded containers and other rubbish in the school yards suggested that students do not transfer prevention and control knowledge into practice, consistent with a study in Indonesia where primary school children have high knowledge of DF, but only a few convert it into practice.(8,11) Indonesian policy makers also have similar concern that community-based dengue prevention will not work due to competing priorities among the community members themselves and poor social economic.

Social and economic factors have a very

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strong role in allowing development of DHF. (12,24)

the

full

There is little training in health education techniques for health practitioners either during their professional training or through in-service training, and therefore, they lack skills and tend to perceive that health education is not part of their work.

The barriers to sustained self-prevention against dengue prevention that emerged in the community members are lack of selfefficacy, lack of perceived benefit, low perceived susceptibility, and unsure perceived susceptibility.

Low perceived benefit of continued dengue prevention practices is a result of lack of concerted action against dengue in their neighbourhood. Traditional medical practices and home remedies were widely.(9) Outbreak control

dengue

prevention

and

Community based care(25,26) The government is working hard to prevent dengue. In contrast, there was an overall lack of confidence that dengue prevention could be effectively undertaken by the community or community members. To control dengue virus transmission, the Indonesian dengue program has been focusing its efforts in community-based mosquito breeding place reduction (27). The program is famous for the slogan ‘‘3M’’ that stands for covering (Menutup) and cleaning (Menguras) water containers, and burying (Mengubur) discarded water containers. However, control of female Aedes aegypti mosquito has proven difficult due to its adaptability to the human-made environment, especially in urban settings where dengue is most prevalent. In addition, use of insecticides in the forms of sprayed liquid insecticide, mosquito coils and insecticide with electric vaporizer are also prevalent.(28)

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Mosquito management within households remains central to the control of dengue virus transmission. Waste management through community mobilization to reduce breeding places at household level could be an effective and sustainable dengue vector control strategy in areas where vector breeding takes place in small discarded water containers.

The coordination of local authorities along with increased household responsibility for targeted vector interventions is vital for effective and sustained dengue control, including the importance of covering and cleaning water jars, removing discarded containers, using Abate, using nets and taking sick children to hospital. The following are some activities which can help the community members to prevent and control the vector: change water in containers within 24 hours, cover water containers properly, bury unused containers and empty bottles (jars, cans and shells), practice 3 M, spray insecticide, plug electric insecticide, use temephos (trade name Abate) in water containers, apply repellent, install window screen apparently, ensure early treatment promptly. (26,29) Biological control is one of effort to use biological agents to control dengue vector.

Several biological agents that has been used and proven to be able to control the vector larvae populations DB / DHF is a group of bacteria which contain endotoxin such as Bacillus thuringiensis serotype H14 and Bacillus spaericus which are specific to kill larva vector not contaminate environment and predators such as fish-eating larvae and Cyclops (copepods), Family Crustaceae (Mesocyclops aspericornis). Predator larva in nature is quite a lot, but that could be used to control vector larva DBD are larva-eating fish such as Kepala timah fish, cetul fish and cupang fish.(23) Knowledge, Attitude Related to Dengue(9)

and

Practice

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Knowledge of causes, disease recognition, prevention, control and care is still not adequate. Knowledge is crucial to identify breeding sites and participate in control activities. Good knowledge of the signs and symptoms of DF is crucial to recognizing the disease and to seeking appropriate health care. Behavioural change towards attaining sustainability in dengue preventive practices may be enhanced by fostering comprehensive knowledge of dengue and a change in health beliefs.

Health education(13,25) Health education is a major means for prevention and control of the National Dengue Control Program (NDCP), and is delivered to communities and in schools.

However, in resource-develop countries like Indonesia, the efficacy of health education is complicated by economic, political and infrastructural factors.

Community involvement in the prevention and control of dengue is essential, but will not be effective while health education is poorly resourced and irregular and lessons on prevention do not result in action.

Community health education is provided through radio, television, billboards, banners, flipcharts, posters and leaflets.

Government policy Though government has done much and spend much fund to control dengue infection still there is increased of cumulative number of infected persons.

Target on Global Strategy: to reduce morbidity by at least 25% by 2020.(7) Main Strategies for Dengue Control in Indonesia :(27) 1. Integrated vector control through 2. Community participation 3. Prompt case management 4. Strengthening surveillance system 5. Outbreak preparedness and response 6. Partnership empowerment

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7. Capacity building, training and survey/research development (11) The following are management of government to gain the success in controlling dengue infection in Indonesia: Program Development 2010-2020(7,27) 1. Strengthening case diagnostic: rapid test, identification of serotypes.

2. Strengthening the community empowerment by suitable and sustainable methods: JUMANTIK (larva observers), COMBI, PLA 3. Strengthening the partnership especially with education sector: larva control by school children & boys Strengthening human resources in medical facilities: training for clinicians, nurses etc.

4. Revitalization of POKJANAL (National Working Group on Dengue Control) 5. Strengthening Surveillance System through Sentinel Lab-based surveillance, propose the collaboration with CDC & NIHRD Indonesia Surveillance of SARI (Severe Acute Respiratory Infection) in 6 Hospitals.

Training for clinician, nurse and others 6. Advocacy to major/ head of district especially in endemic areas in order to building commitment on Dengue control program: increase budgeting for JUMANTIK activities or larva/mosquitoes control activities 7. Vaccine development research.

Proactive surveillance(30,31) Surveillance and improved reporting of dengue cases is also essential to gauge the true global situation as indicated in the objectives of the WHO Global Strategy for Dengue Prevention and Control, 20122020. More accurate data will inform the prioritization of research, health policy, and financial resources toward reducing this poorly controlled disease.

Surveillance for dengue and DHF/DSS can be of two basic types, reactive or proactive. Most endemic countries conduct reactive surveillance, with health

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authorities waiting until the medical community recognizes transmission before reacting to implement control measures.

The proactive surveillance system also monitors all cases of hemorrhagic disease and all cases of viral illness that have a fatal outcome. This is done working in close collaboration with infectious disease physicians who would normally see such cases of severe and fatal disease. All cases reported are investigated, and blood specimens-as well as tissue specimens in fatal cases-are obtained for virologic and serologic study.(5) Conclusion Differences in the risk of acquiring dengue in Indonesia from year to year may be due to changes in the epidemiology of dengue in the country, particularly in Jakarta and Bali, or changes in traveller behaviour.

Barriers to prevent dengue are categorized as low self-efficacy to execute preventive measures, perceived lack benefit of individual preventive measures, and unsure susceptibility of getting dengue.

Low perceived benefit of continued dengue prevention practices is a result of lack of concerted action against dengue in the community. Human behaviours and activities, as well as demographic, social and possibly climate changes during rainy season also contribute greatly to the increased incidence and geographical spread of the disease.

A community based environmental management embedded in a routine control programme is effective at reducing levels of Aedes infestation. Adequate funds, technical and human capacity, collaboration and cooperation within the community and government is very important.

Local prevention and control activities, involving community members and supported through health education within

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the community and in schools, offers potential to reduce the prevalence of dengue.

Suggestions Health department supposed to strengthen the reporting system of dengue cases in order to get valid data by create data exchanging system to facilitate the process of data exchanging from Health centres to Hospital and otherwise.

Proactive surveillance can help in decreasing IR and CFR if done properly by all provinces.

There is in need education of medical community and involvement of community in practicing planning of government to control DF. The above long-term program for prevention and control of epidemic dengue will take several years to implement and refine. In general, the response to news of a threatening epidemic should involve community participation. Ultimate success of the program will depend on community participation and cooperation by citizens (most transmission occurs in the home).

Therefore, considerable effort is being placed on community education.

The need for a strong multidisciplinary and multisectoral collaboration in implementing the strategic plan is obvious.

Travellers to Indonesia need to take appropriate precautions to avoid being bitten by mosquitoes.22

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17. Ratnam I, Black J, Leder K, Biggs B–., Matchett E, Padiglione A, et al.

Incidence and seroprevalence of dengue virus infections in Australian travellers to Asia. Eur J Clin Microbiol Infect Dis. 2012 Jun;31(6):1203–10.

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20. Gurugama P, Garg P, Perera J, Wijewickrama A, Seneviratne SL. Dengue viral infections; Indian J Dermatol. 2010;55(1):68–78.

21. Dan LL, Dennis LK, Larry J, Anthony SF, Stephen LH, Joseph L. Harrison’s Principle of internal medicine 18th ed. New York: McGraw-Hill, Health profession Division; 2013: p.1028,1621,16311632 22. Jawetz, Melnick, Adelberg.Medical microbiology 25th ed. New York: McGraw-Hill, Health profession Division; 2010: p.549-550 23. Supratman S. Masalah vector demam berdarah dengue (DBD) dan pengendaliaanya di Indonesia; Buletine jendela epidemiologi;Jakarta; MOH of Indonesia; Aug 2010 (2); 25-30 24. TDR | Guidelines needed to predict, detect and manage dengue outbreaks [Internet]. WHO. [cited 2014 Jan

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18].

Available from: http://www.who.int/tdr/news/2013/d engue_outbreaks/en/index.html 25. Abeyewickreme W, Wickremasinghe AR, Karunatilake K, Sommerfeld J, Axel K. Community mobilization and household level waste management for dengue vector control in Gampaha district of Sri Lanka; an intervention study. Pathog Glob Health. 2012 Dec; 106(8):479– 87.

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28. Kusriastuti R, Sutomo S. Evolution of dengue prevention and control programme in Indonesia;WHO Dengue bulletine 2005 (25):1-7 29. Umar F. Manajemen demam berdarah berbasis wilayah; Buletine jendela epidemiologi; Jakarta; Ministry of Health of Indonesia; August 2010(2);1-19 30. Anonymous. Dengue still major threat in Indonesia despite lower death rate. McClatchy - Tribune Business News [Internet].

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DEN-DI PACK (DENV DIAGNOSTIC PACKAGE) AS A NEW EARLY DETECTION KIT FOR DENGUE VIRUS INFECTION AS BEST INVESTMENT IN COMMUNITY BY USING NONSTRUCTURAL-1 (NS1) ANTIGEN AS MARKER IN URINE SAMPLE : BIOMOLECULAR APPROACH Nurul Cholifah Lutfiana, Athaya Febriantyo Purnomo, Dewa Ayu Megayanti FACULTY OF MEDICINE BRAWIJAYA UNIVERSITY MALANG

INTRODUCTION Dengue fever is currently one of the most important mosquito-borne diseases that affect humans in terms of morbidity and mortality. The causative agents of these syndromes, dengue viruses, are members of the Flaviviridae family and occur as four antigenically related but distinct serotypes, designated DEN-1, DEN- 2, DEN-3, and DEN-4. Over half the world’s population lives in areas potentially at risk for dengue transmission, making dengue the most important human viral disease transmitted by arthropod vectors in terms of morbidity and mortality.7 Dengue fever is endemic in all continents except Europe and epidemic dengue hemorrhagic fever (DHF) occurs in Asia, Africa, Caribbean, the Americas, and some Pacific islands. Dengue has been reported in over 100 countries and 2.5 billion people live in areas where the disease is endemic1. There has been a gradual increase in the global incidence of dengue since the year 20002 which is believed to be due to factors such as rapid urbanization, expanding human population and activities, increased global travel to endemic areas, and failure to control the primary vector populations, it is Aedes aegypti.3,8 Today about 2.5 billion people, or 40% of the world’s population, live in areas where there is a risk of dengue

transmission.

The World Health Organization (WHO) estimates that 50 to 100 million infections occur yearly, including 500,000 DHF cases and 22,000 deaths, mostly among children. Nearly all dengue cases reported in the 48 continental states were acquired elsewhere by travelers or immigrants.4 In Indonesia itself, there has been reported an outbreak happened in easternmost of Indonesia. Overall hospital records accounted for 172 suspected outbreak cases. The estimated outbreakassociated case fatality rate among all suspected dengue cases was 1.2%. A seven-year retrospective review of hospital records in Merauke showed negligible disease reporting involving hemorrhagic disease prior to the outbreak. 5 The last 50 years witnessed a resurgence of dengue fever (DF) epidemics and an emergence of dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) throughout tropical and subtropical regions around the world. 6 As there is currently no specific therapy or commercially available vaccine to prevent or treat the infection, supportive therapy such as fluid replacement is the only treatment for severe forms of the disease.9 Early detection of disease transmission and outbreaks is critical for surveillance programs that are aimed at minimizing morbidity by controlling disease spread.3 Early diagnosis also enhances disease surveillance and control by accurate and prompt identification of

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active disease clusters. This is important in Indonesia where dengue is endemic and is more commonly reported among adults, who are more prone to develop severe complications, especially when associated with comorbid conditions such as diabetes and hypertension.10 At present, laboratory confirmation of dengue relies on demonstration of the presence of DENV by (a) isolation of DENV from patient serum, (b) detection of viral RNA by reverse transcription– polymerase chain reaction (RT-PCR), and (c) detection of dengue-specific antibodies (immunoglobulin M [IgM]=IgG) by using enzyme-linked immunosorbent assay (ELISA).6,11,12 Each method has its own advantages and disadvantages that define criteria for their selection in different settings.

Virus isolation coupled with immunofluorescence is an effective technique for early diagnosis of dengue.

However, it is time-consuming and due to the short duration of viraemia is only sensitive for samples taken up to 5 days post-onset of infection. The second one, RT-PCR has proven to be a highly sensitive and powerful alternative to virus isolation as it has a wider window of detection and allows for both quantitation of viral loads and serotyping.13 However, molecular techniques such as PCR require specialised equipment, and there has been little progress in the standardisation of protocols, which has limited their utility in lower socio-economic countries where there is a need for simple and affordable testing.14 The usage of dengue-specific antibody detection assays, also, though cost-effective, is limited in the early phase of disease as antibodies become detectable only around the fifth day upon the onset of disease. The antibody assays ideally require appropriately timed paired serum samples for the confirmation of an acute dengue infection.6,11,12

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Preventing dengue infection not only benefits the travelers disease earlydetection but also prevents the spread of autochthonous dengue transmission in areas where competent vector is abundant.

Ideal early detection method is the specific, noninvasive, rapid assay and affordable value for all society especially low-economic society which DENV infection mostly happened in developing countries. Nonstructural 1 (NS1) Antigen is the exists as an intracellular, membrane associated, and as an extracellular form secreted from DENV infected mammalian cells to serum and later study shows it could be found on urine which is promising to detect DENV infection with affordable cost and effective result.

Therefore we have an idea of making a dipstick detection kit of DENV infection as preventive action toward diagnosing whether dengue fever and dengue hemorrhagic fever earlier and prevents the spread of DENV in endemic areas.

METHODS This scientific paper is based on literature review through biomolecular medicine that describes how the NS-1 Antigen strip uses as early diagnostic kit for dengue infection from urine sample.

Which is this combination methods of NS1 antigen can give new solution for traveler detect dengue fever infection faster, easier, and cheaper. In person with dengue high fever there are NS1 antigen in their serum and urine. Usual method to measured this level by ELISA. But this method needs more time and cost. Then, we will make an early diagnostic kit with urine sample.

Method of Antibody anti-Dengue NS1 titer, measured Antibody anti-Dengue NS1 by serotype-specific IgM/IgG ELISA then conjugate IgM/IgG with a horseradish peroxidase-linked second antibody. It will be made in the dipstick using blotting

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method and given the antibody to the sticks in order to used as diagnostic kit.

With this method, we can cut the time and cost toward diagnosing Dengue Fever, because with this dipstick, with usual amount of ELISA can diagnose with one sample, can be improved to even more samples to be diagnosed by these dipsticks because the antibody that has been produced in ELISA could be attached on the huge amount of dipsticks.

Data collection methods in this paper obtained from literature (literature review) based on issues. The information from literature such as journals and medical books. The method of data analysis literature conducted through two approaches, namely: 1. Method of exposition, that the presented data and facts that may ultimately sought correlations between these data.

2. Analytic methods, namely through the analysis of data or information by giving the argument through logical thinking and were then taken to a conclusion.

RESULTS The study of NS1 antigen has been done by many researcher. Method use usually by ELISA and Immunochromatography strip in serum sample. In a study conducted by Universidad del Valle and Universidad Industrial de Santander in Colombia between 2004 and 2008 showed that NS1 antigen detection by NS1 strip in serum sample can be performed for 15-30 minute without additional equipment required.

The sensitivity and spesificity of NS1 antigen strip is about 57.7 - 61.5% and 93.3-95.3%.16 In another study of NS1 antigen strip, EDEN study in 2011 compare the sensitivity and specificity of the NS1 strip with the 1997 and 2009 WHO

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classification schemes for the diagnosis of acute dengue fever and evaluate the sensitivity of the tests. The NS1 strip had a sensitivity and specificity of 77.3% and 100%, respectively, at 15 minutes, and 80.5% and 100%, respectively, at 30 minutes ( Table 1 ).17

(Table 1. Sensitivity and Specificity of the Dengue NS1 Ag Strip test and 1997 and 2009 WHO classification schemes relative to RT-PCR and virus isolation.)

Recently, there were several case reports detection of viral genome in saliva and urine by real-time reverse transcriptase–polymerase chain reaction.18 There was probability that NS1 Antigen may be detected in urine. Detection of nonstructural protein 1 (NS1) in urine samples by the DENV-NS1 strip will be an ideal method for early detection of virus infection as it is noninvasive, rapid, and does not require any equipment such as a centrifuge.

Newly found, first result of detection of DENV-NS1 in urine samples and compare the result of DENV-NS1 strip to standard ELISA method. This study recruited 85 patients aged 6 months to 18 years who were clinically suspected of having dengue virus infection admitted at the Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital during March 2009 to July 2011. The serum/urine NS1 detected by ELISA and strip are shown in Table 2.19 Tabel 2. Results of NS1 detection in serum and urine samples by ELISA and the strip technique Positive rate of serum NS1 by ELISA was highest in DF (94.7%) but lower in DHF (66.7%). Compared to ELISA, the strip method showed slightly lower positive rates in both DF (89.5%) and DHF (61.1%). We could detect NS1 in urine samples in both groups of patients.

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Positive rate of urine NS1 by ELISA was similar in DF (68.4%) and DHF (63.9%).

Compared to ELISA, the strip method showed lower positive rates in both DF (52.6%) and DHF (47.2%). Serum NS1 ELISA in primary DENV infection gave higher positive rate (88.2%) than that in secondary infection (71.1%). However, positive rate in urine samples was similar in primary (70.6%) and secondary infection (63.2%). Thirty patients from the control group had negative DENV NS1 antigen for both serum and urine, which reflected the specificity of the test. 19 The first evidence of DENV NS1 in urine samples from patients with DENV infection. In the experiment found similar positive rate of NS1 in urine in patients with DHF and DF. Yet, the positive rate was 95.8% when serum NS1 was positive in DHF but only 72.2% in DF. The higher positive rate of NS1 in urine samples in DHF than in DF, and higher than the positive rate of the virus itself, suggested that detection of DENV NS1 in urine could be due to plasma leakage or higher production of viral antigen by infected kidney cells.

A previous study demonstrated leaking of small-sized proteins such as albumin (MW, 59 kDa) and transferrin (MW, 79 kDa), and, to a certain extent, IgG as well, and suggested impaired charge but retained sizedependent sieving mechanism of glomerular filtration.29 Dengue NS1, a 50kDa nonstructural glycoprotein, is secreted as a 300-kDa hexamer from DENVinfected cells, which appears as a globular high-density glycoprotein particle.30 The amount of NS1 in urine could possibly reflect protein leak and would be important to monitor over time in patients developing DF or DHF. The discrepancy in positive rate of NS1 in blood between DF and DHF and between primary and secondary infection has been reported.32 Previous report of 98.9% sensitivity of the serum DENV NS1 strip compared to the ELISA method.31 For urine, the strip

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method showed only 73.9% to 76.9% sensitivity compared to the ELISA method. There may be some technical problems such as pH, concentration, etc., that affect the sensitivity of the assay.

DISCUSSION Dengue Virus (DENV) The dengue virus (DENV) is the cause of dengue fever. It is a mosquitoborne single positivestranded RNAvirus of the family Flaviviridae; genus Flavivirus. All four serotypes can cause the full spectrum of disease.20 Its genome is about 11,000 bases that codes for three structural proteins, capsid protein C, membrane protein M, envelope protein E; seven nonstructural proteins, NS1, NS2a, NS2b, NS3, NS4a, NS4b, NS5; and short noncoding regions on both the 5' and 3' ends.20 Typically, people infected with dengue virus are asymptomatic (80%) or only have mild symptoms such as an uncomplicated fever. Others have more severe illness (5%), and in a small proportion it is life-threatening.21,22 The incubation period (time between exposure and onset of symptoms) ranges from 3–14 days, but most often it is 4–7 days.23 Therefore, travelers returning from endemic areas are unlikely to have dengue if fever or other symptoms start more than 14 days after arriving home.24 Children often experience symptoms similar to those of the common cold and gastroenteritis(vomiting and diarrhea)25 and have a greater risk of severe complications,24,26 though initial symptoms are generally mild but include high fever.26 The reason that some people suffer from more severe forms of dengue, such as dengue hemorrhagic fever, is multifactorial. Different strains of viruses interacting with people with different

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immune backgrounds lead to a complex interaction. Among the possible causes are cross-serotypic immune response, through a mechanism known as antibodydependent enhancement, which happens when a person who has been previously infected with dengue gets infected for the second, third or fourth time. The previous antibodies to the old strain of dengue virus now interfere with the immune response to the current strain, leading paradoxically to more virus entry and uptake.27

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secondary infection has been reported.32 Clinical observations have shown that dengue NS1 antigen can be detected in the circulation during DENV infection and it elicits a specific immune response.33Later studies further demonstrated the presence of dengue NS1 antigen in acute-phase sera of infected individuals. In cultures, the levels of NS1 protein correlated with infectious titers of DENV.34,35

It shows that vaccine for this dengue fever is hard to be made, because the ability of the virus to make certain serotype in the body and the vaccine should have all of these virus’ antigen in order to produce effective antibody in the body. Moreover there is the tendency to not giving a necessary immunization but unfortunately go into the illness condition.

Over the recent past, several dengue NS1 antigen assays are available commercially for the detection of dengue NS1 antigen in human sera.The study of NS1 antigen has been done by many researcher. Method use usually by ELISA and Immunochromatography strip in serum sample, but later study shows that there is NS1 Antigen in the urine marker because of the plasma leakage which contain the NS1 antigen and this protein freed in urine because it passes the filtration system of glomerulus in kidney.17,30 Serum and Urine comparison have already been done in certain experiments. It resulted on insignificant differences between the result of diagnosis whether using serum or urine.19 It means that it is promising when we use NS1 antigen in terms of dipstick as early detection of DENV infection. Moreover the specificity and sensitivity is not going to be changed whether in primary or secondary infection.19

Nonstructural 1 Antigen (NS1 Ag) as DENV Sera and Urine Marker

Comparison between Laboratory Confirmation and NS1 Antigen Assay

Dengue NS1 is a highly conserved 46kDa nonstructural glycoprotein that both exists as an intracellular, membraneassociated and as an extracellular form secreted from DENVinfected mammalian cells .15 The amount of NS1 in urine could possibly reflect protein leak and would be important to monitor over time in patients developing DF or DHF. The discrepancy in positive rate of NS1 in blood between DF and DHF and between primary and

Laboratory confirmation can be made from a single acute-phase serum specimen obtained early (≤5 days after fever onset) in the illness by detecting DENV genomic sequences with RT-PCR or DENV nonstructural protein 1 (NS1) antigen by immunoassay. Later in the illness (≥4 days after fever onset), IgM anti-DENV can be detected with ELISA. For patients presenting during the first week after fever onset, diagnostic testing should include a test for DENV (PCR or NS1) and IgM

Vaccine Research Nowadays, there is no human vaccine available. Developing a vaccine against the disease is challenging. With five different serotypes of the dengue virus that can cause the disease, the vaccine must immunize against all five types to be effective. In September 2012, it was announced that one of the vaccines had not done well in clinical trials.28

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anti-DENV. For patients presenting >1 week after fever onset, IgM anti-DENV is most useful, although NS1 has been reported positive up to 12 days after fever onset.

Presence of DENV by PCR or NS1 antigen in a single diagnostic specimen is considered laboratory confirmation in patients with a compatible clinical and travel history. IgM anti-DENV in a single serum sample suggests a probable, recent DENV infection. IgM anti-DENV seroconversion in acute- and convalescentphase serum specimens is considered laboratory confirmation of dengue. NS-1 antigen detection strip in urine can give new solution for traveler detect dengue fever infection faster, easier, and cheaper.

The use of urine samples has advantages over the use of other samples for laboratory testing. Urine samples are easy to collect without invasive procedures, and they can be used for the dengue diagnosis of newborns, children, and patients with hemorrhagic symptoms. 4 The performance characteristics of NS-1 antigen detection, rRT-PCR, and IgM antibody detection in the acute plasma specimen are shown in Table 3.

Table 3. Diagnostic accuracy of NS-1 antigen detection, rRT-PCR, and IgM antibody detection on acute plasma specimens Figure 1. Sensitivity of NS-1 antigen, rRT-PCR, and IgM antibody based on days fever presentation According to Figure 1, NS-1 antigen has 54% of sensitivity but has specificity a whole 100%. Specificities of NS-1 antigen detection, rRT-PCR, and IgM antibody detection were 100%, 96% and 88% respectively.

NS-1 antigen sensitivity peaked in the early stages of fever (three days of fever at presentation).

IgM antibody sensitivity rose later36, peaking in patients presenting with five

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days of fever. Compared to IgM, IgM antibody sensitivity rose later, peaking in patients presenting with five days of fever.

According to specificity section of Table 3, NS-1 Antigen could bring a “definite” diagnosis that somebody is having DENV infection, with rRT-PCR followed with 95.6%. However, NS-1 antigen has advantage, that this glycoprotein could bring a cost-effective towards community compared to rRT-PCR, which is it requires specialised equipment, and there has been little progress in the standardisation of protocols, which has limited their utility in lower socio-economic countries where there is a need for simple and affordable testing.14 NS-1 Antigen dipstick could be an aid for low socio-economic society because its cost which sourced from ELISA method could be divided well in terms of large amount of dipstick produced for diagnosing DENV Infection, which is known Dengue cases happened mostly at developing countries.

Application Early Detection Kit NS1 Antigen Strip in Traveler Travellers play an essential role in the global epidemiology of dengue infections, as viraemic travellers carry various dengue serotypes and strains into areas with mosquitoes that can transmit infection.37 Furthermore, travellers perform another essential service in providing early alerts to events in other parts of the world. An increase in cases in travellers could be due to increased travel activity to dengue endemic areas,for instance.38 Rapid and accurate detection of dengue virus (DENV) infection from acute-phase viremic blood samples from patients with a fever contributes greatly to patient management in hospitals and control measures in public health. In addition, rapid detection of imported dengue cases at airports can help to reduce the annual local outbreaks in a country where dengue is not endemic.

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In a study in Taiwan reported on screening for fever at airports in Taiwan as part of active surveillance for a panel of notifiable infectious diseases, such as dengue, gastroenteritis caused by enteric bacteria, malaria, and chikungunya.39,40 A pilot study examining the application of the NS1 Ag strip test for on-site detection of imported dengue cases at airports was started 18 June - 12 September 2008, among the 22 positive serum samples, 17 (77.3%) were NS1 Ag test positive, 17 (77.3%) were RT-PCR positive, and 3 were IgM positive. These findings demonstrate the usefulness of the NS1 Ag rapid test kit in detecting imported dengue cases at airports. After the successful evaluation, the DENV NS1 rapid test is now routinely applied for on-site detection of imported dengue cases at airports in Taiwan.41 The NS1 Ag strip rapid test offers several advantages over current routine assays (ELISA and RT-PCR), such as rapidity, simplicity, high sensitivity with a longer detection time (1 to 9 DPO) for primary infection, and excellent specificity (100%). Most important, the patients can be quickly diagnosed as positive and advised to go to hospitals for medical treatment due to the high positive predictive value. 41 As the continuation of this diagnostic kit, we need to implement it to the first gate of the travelers come to one area, such as airport, harbor, and station.

Firstly, the travelers who come from the dengue-endemic area is going to checked their vital sign, whether they had a fever or not. Then, the doctor responsible in public transportation station can conduct anamnesis for the traveler who got fever, to collect the data since when they got fever and could be measure whether this traveler suspect dengue or not. The suspected dengue traveler who got fever since a day ago, could take the urine sample for doctor diagnosis and get the early treatment from the doctor. Therefore

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we could prevent the further spread of DENV infection to the other area.

However for the area which have already endemic, fortunately this NS1 Ag strip is not only can be used in the public transportation station, but can be used anywhere the person wants. Thus, the people who got fever in the endemic area could be diagnosed earlier whether they got DENV infection or not, so they could get the early treatment as well. We have made and showed that NS1 Ag strip is applicable to use. Hopefully, NS1 Ag Strip in urine could be more applicable to use as people/travelers can use this kit with no need to go to laboratorium to take serum sample. Further research is needed to improve sensitivity and evaluate costeffectiveness of these kit.

CONCLUSION 1.

Dengue viral (DENV) infection can lead to a broad range of clinical spectrum ranging from asymptomatic, undifferentiated fever, dengue fever (DF), and dengue hemorrhagic fever (DHF). Early diagnosis of DENV infection is important in patient management and control of dengue epidemic. Ideal early detection method is the specific, noninvasive, rapid assay and affordable value for all society especially low-economic society which DENV infection mostly happened in developing countries.

2. Detection of nonstructural protein 1 (NS1) in urine samples by the DENVNS1 strip will be an ideal method for early detection of virus infection as it is noninvasive, rapid, and does not require any equipment such as centrifuge or ELISA when the amount sample could be made bigger these dipsticks.

3. NS-1 Antigen could be a promising detection kit. Far away before the

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suspected person want to test whether they got DENV infection or not, Dipsticks could be provided and rapidly (15-30 minutes) diagnosed whether or not the person is in illness with the same reliability and specificity.

Therefore we proposed this idea for a better detection and prevent the developing of the DENV infection.

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nonstructural protein NS1 is an atypical barrel-shaped highdensity glycoprotein. Proc Natl Acad Sci U S A 108:8003–8008.

31. Chuansumrit A, Chaiyaratana W, Pongthanapisith V, Tangnararatchakit K, Lertwongrath S, Yoksan S .2008. The use of dengue nonstructural protein 1 antigen for the early diagnosis during the febrile stage in patients with dengue infection. Pediatr Infect Dis J 27:43–48.

32. Chaiyaratana W, Chuansumrit A, Pongthanapisith V, Tangnararatchakit K, Lertwongrath S, Yoksan S .2009. Evaluation of dengue nonstructural protein 1 antigen strip for the rapid diagnosis of patients with dengue infection. Diagn Microbiol Infect Dis 64:83–84.

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Myanmar Border. Trans R Soc Trop Med Hyg. Jan 2011; 105(1):32-37.

37. Wilder-Smith A, Wilson ME. Sentinel surveillance for dengue: international travellers (unpublished report).

38. World Health Organization.2009 .Dengue: guidelines for diagnosis, treatment, prevention and control - New edition.

39. Cardosa, M. J., T. Phaik, N. Sham.

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40. Charrel, R. N., X. de Lamballerie.

2002. Low specificity of a immunochromatographic serological assay for diagnosis of dengue fever in travelers returning with malaria. Clin. Diagn. Lab. Immunol. 9:1400.

41. Pei-Yun, S., Jyh-Hsiung H., 2004.Current Advances in Dengue Diagnosis Clin. Diagn. Lab. Immunol. 11(4):642.

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TABLE AND FIGURE Table 1

Table 2

Table 3

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Figure 1

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CROSS SECTIONAL STUDY : RISK FACTOR AND PREVENTION OF TRAVELERS’ DIARRHEA IN INDONESIA AS STANDARD FOR INTERVENTION AND GOVERNMENT POLICY Puspita Widyasari, Kaorie Bunga Saviestya Medical Faculty of Brawijaya University INTRODUCTION Development of transportation in the global mobility of society and escalating many products and service which rapidly obtained everywhere in the world influence the explisive growth of tourism. Tourism is the fatest growing industry worldwide. By the year 2020, the number of in country arrivals is projected to double estimate 1560 project. In one day, people can travel to everywhere such as rural areas or remote areas where there are unique of wildlife. When traveling to these areas, people can be exposed to uncommon pathogens in their home location (2). The movement of populations shapes the patterns and distribution of infectious diseases globally.

Travel medicine is very important for travelers. Travel medicine is not only devoted to the health of traveler who visit foreign countries, but also determined by environmental situation in foreign countries. It’s very important for someone who will have vacation to know about risk factor in their destination. It is an interdisciplinary speciality concerned not only with personal safety of travelers and the avoidance of environmental risks but also with the prevention of infectious diseases during travel (1). Timely and accurate diagnoses are often essential to prevent life-threatening stages of disease from developing

(2). The risk factor of becoming infected will vary according to the standards of accomodation, the purpose of the trip and the itinerary within the area, hygiene and sanitation, the hygiene of food and drink in the trip or journey, the protection of himself such as use repellant in areas which is endemic of malaria or dengue fever, general precautions, the modes of transmission for different infectious diseases, and as well as the behaviour of the traveller. There are some diseases that can be prevented by vaccination, but for which no vaccines exist, there are some important dangerous diseases (4).

In developing countries and tropical areas such as in Indonesia, travelers’ diarrhea (TD) is an important health issue among travelers (3).The growing importance of international travel, the occurrence and severity of traveler's diarrhea have become a major public health issue. Diarrhea often appear in migrating groups or traveler groups when moving from one region of the world to another. It has played a major role in the outcome of many wars up to the 19th century (5).

Morbidity rates of TD have been reported up to 55% by travelers, but there is no exact report from each country in the world (3). In case 6,086 any gastrointestinal infection to seek medical care at a GeoSentinel clinic post travel during 2000 to 2005. Indonesia included to highest

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risk area for gastrointestinal complaints in ill travelers with attack rate around >40% (6). Although travelers’ diarrhea is self limiting and is usually spontaneously cured within a few days, but it can disturb a planned business or pleasure trip, can be worse, and can make someone death (3). A commonly used definition of traveler's diarrhea is the passage of three or more unformed stools per day, together with one or more additional symptoms or signs of enteric infection including nausea, vomiting, fever, abdominal pain or cramps, tenesmus, or fecal urgency, after leaving a home region to travel to a distant location.

MATERIAL AND METHODS The information from data obtained from the database of us is made by the International Society of Travel Medicine (ISTM), by an active clinical group within the American Society of Tropical Medicine and Hygiene (ASTMH), and the results from basic health research (RISKESDAS) of Indonesian Ministry of Health.

However, there are some data that was not available so we took data from online print media that came from reliable and formal sources.

This research is cross sectional study which aimed to explain about risk factor and epidemiology of diarhea cases in Indonesia and how to prevent the diseases. We hope that

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our results contribute to reducing health risks for travelers and decreasing the burden on the Indonesian public health system.

Travelers’ Diarrhea variable is a subject that will be subjected to be preventing. At the end, this paper is include the type of library research and if we classified from the purpose of this research paper, it will influence the future policy that the researcher hope for this nation`s better in management of prevention travelers diseases.

RESULT A. Epidemiology Diarrhea can be defined as a change in stool consistency apart from the frequency of bowel movements. It is said when the stool is more watery diarrhea than usual. Diarrhea can also be defined when a bowel movement three times or more, or watery bowel movements but do not bleed within 24 hours. While the bloody diarrhea is defined as dysentry.

Travelers' diarrhea (TD) is the most common illness affecting travelers. Each year between 20%-50% of international travelers, an estimated 10 million persons, develop diarrhea. The onset of

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TD usually occurs within the

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Studies

of

traveler’s

diarrhea evolved from the first week of travel but may occur at any time while traveling, and even after returning home. The most important determinant of risk is the traveler's destination. Highrisk destinations are the developing countries of Latin America, Africa, the Middle East, and Asia. Persons at particular high-risk include young adults, immunosuppressed persons, persons with inflammatorybowel disease or diabetes, and persons taking H-2 blockers or antacids. Attack rates are similar for men and women. The primary source of infection is ingestion of fecally contaminated food or water.

descriptive in the 1960s (8), to the establishment of etiology and risk factors in the early 1970s (9,10), to prophylaxis of illness with anti-microbials in the late 1970s and 1980s (11), to self-treatment of diarrhea in the 1980s and 1990s (12,13), and finally to new agents for treatment based on developing drug-resistance patterns (14,15).Indonesia is high risk area of travelers’ diarrhea.

Up to 40% of tourists may develop 3 or more loose bowel motions a day within the first week of travel. A variety of germs can be responsible for this infection. A traveller’s

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medical kit containing appropriate therapy can rapidly improve the symptoms.

The figure below shows that diarrhea was included in the 22 promote disease for deaths in all age groups in Indonesia(16).

Table: Trends in Causes of Death All Age RISKESDAS 2007(Reference: Result from Riskesdas 2007)

There are several diseases that have the potential outbreaks/epidemics often occur in Indonesia, such as Dengue Hemorrhagic Fever (DHF), diarrhea, and chikungunya.

Diarrhea resulted in many deaths and greatly impact the economic loss. In 2008 it was reported outbreaks of diarrhea in

15 provinces by 8443 as the number of patients, number of deaths of 209 people or a CFR of 2.48%.

The number of provinces, the number of cases and CFR of outbreaks of diarrhea in the year

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2000 - 2008 can be seen in the table below. From these data it was found that each year the number of cases of diarrhea in Indonesian fluctuating and uncertain amount. Similarly, the number of provinces that

experienced outbreaks with cases of diarrhea each year is unpredictable and not

experience a significant decline.

Table: number of cases, the CFR, and the number of provinces with Diarrhea out break in 2000 2008(reference: Ditjen PP – PL, Depkes RI, 2009)

The results of basic health research (RISKESDAS) in 2007declared a national prevalence of clinical diarrhea (based diagnosis of health personnel and symptoms) is

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9.0% with arange of 4.2% 18.9%. A total of 14 provinces have diarrhea prevalence above the national prevalence, with the highest prevalence in the province of Nanggroe Aceh Darussalam and the lowest in the province of Yogyakarta (16).

Figure: The number of cases of outbreaks of diarrhea and CFR in Indonesia in 2000 – 2008

B. Risk factor Risk factors for traveler's diarrhea in general is: 1.Destination (Highest risk in developing countries such as Indonesia) 2.Country of origin (Persons coming from developed countries at highest risk) 3.Previous exposure (Lower risk among those with lots of developing country exposure) 4.Duration of stay (Longer the stay, lower the risk) 98% of travelers made at least 1 alimentary mistake during the first 3 days of stay (7) 5.Socio-economic status (High status = less chance ofdeveloping protective immunity) 6.Age (Very young: fecal oral and Young adult: adventurous) 7.Season (Highest in summer, rainy or post monsoon seasons) 8.Mode of travel (Organized travel may be safer) 9.Standard of accomodation (Fairly unpredictable)

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10.

5-star travel itineraries might help, but not all travelers can afford this kind of travel and cannot insist on traveling during safer seasons.

11.

Dietary Errors : Water Water often meets standards leaving the chlorination plant, old pipes and unhygienic practices. Cross contamination often occurs in rainy season.

12.

Dietary Errors : Food • Food grown with night soil • Personal hygiene of food preparer • Storage of food • Cooking for oneself is safest but impractical (17) One of the important things that contribute to the incidence of diarrhea by the time traveler is the condition of the food and drinks as well as environmental conditions. The risk factor in Indonesia related to describe the state of the environment is the percentage of households to access to drinking water, the percentage of households by source of drinking water, the percentage of households with drinking water from pumps/ wells/ springs according to the distance to the end of the shelter dirt/ stool and the percentage of households by ownership of facility defecation. It will indirectly affect the state of the environment and the condition of the food and drinks in Indonesia is very likely consumed by the traveler who visited Indonesia(16).

1. Access to drinking water Based on data Susenas 2008, BPS categorize sources of

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drinking water used by households into two major groups, namely drinking water sources protected and unprotected sources of drinking water. Protected drinking water source consists of bottled water, plumbing, pumps, protected spring, protected wells, and rainwater. While drinking water sources consist of unprotected wells, unprotected springs, rivers, and other sources.

Susenas of 2008 states that the percentage of households that have protected drinking water sources are the lowest in the province of Bengkulu, Lampung and Kalimantan followed by Central (16).

2. Application of clean water Total water consumption

per capita household with public healthrisks associated with hygiene. Riskesdas 2007 states that nationally there are 16.2% of households that are low in waterusage and households which have access to basic (minimum) to get clean water of 26.9%. Provinces household access to clean water is still low among other Gorontalo, West Sulawesi, and West Sumatra.

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3. Physical quality of drinking water Good physical quality of drinking water if the water is not cloudy, odorless, tasteless, colorless, and no foaming. There are 15 provinces that the percentage of physical quality of drinking water under the national percentage, which is the lowest in Central Kalimantan. In 2006, among the 10 ASEAN countries, the people who use water resources has reached 80% or more by 7countries.

Picture: percentage of population using clean water sources and sanitation facilities in the countryhealthy-ASEAN and SEARO in 2006 (reference: World Health Statistica2009)

Most importantly for security and separately travelerer so they are comfort in Indonesian is Indonesian society must think how to be have to live clean, healthy, and hygiene condition.

Clean and healthy behavior by Riskesdas 2007, the percentage of households that do not meet

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the criteria for Clean and Healthy Behaviors are the lowest in Papua, East Nusa Tenggara, Gorotalo, Riau, andWest Sumatra.

Based on survey results Riskesdas 2007, covering hygienic behavior in bowel habits and hand washing. Proper hand washing behavior is when residents wash their hands with soap before eating, before preparing food, after defecation, after cleaning a baby/ child, and after touching with the birds/ animals. Result from Riskesdas nationally in 2007 only 23.2% of the population in Indonesia, which has a habit of washing hands properly. The low awareness of goodhand washing with this list of risk factors that increase the potential for the occurrence of diarrhea especially when traveling.

C. Preventive efforts For travelers to high-risk areas, several approaches may be recommended that can reduce, but never completely eliminate, the risk for TD. These include instruction regarding food and beverage selection, use of agents other than antimicrobial drugs for prophylaxis, and use of prophylactic antibiotics.

Carrying small containers of alcohol-based hand sanitizers (containing ≥60% alcohol) may make it easier for travelers to clean their hands before eating (18).

1. Vitamin supplementation

A

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Giving vitamin A is very important in children when exposed to diarrhea, because it can increase endurance(16).

2. Knowledge base for the traveler The knowledge base for the travel medicine provider includes epidemiology, transmission, and prevention of travel associated infectious diseases; a complete understanding of vaccine indications and procedures; prevention and management of noninfectious travel associated health risks; and recognition of major syndromes in returned travelers (e.g., fever, diarrhea, and rash) (1).

3. Vaccination The pretravel visit should be used to update vaccinations.

The new oral cholera vaccine has been shown to provide limited protection against some forms of traveller’s diarrhea.

You should discuss this with travel health specialist (1).

4. Eating and drinking safely and healthy The risk of infection is reduced by taking hygienic precautions with all food, drink and drinking-water consumed when travelling and by avoiding direct contact with polluted recreational waters (19). The key prevention strategy is persons are challenged to select safe foods, commonly found buffets may not be safe, and flight attendants may unwittingly serve an additional challenge (17). Furthermore, many of the factors that ensure food safety, such as restaurant

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hygiene, are out of the traveler’s control (18).

5. Oral rehydration salts should be carried to combat dehydration in case of severe diarrhea (17) 6. Nonantimicrobial Drugs for Prophylaxis The primary agent studied for prevention of TD, other than antimicrobial drugs, is bismuth subsalicylate (BSS), which is the active ingredient in PeptoBismol. Studies from Mexico have shown this agent (taken daily as either 2 oz of liquid or 2 chewable tablets 4 times per day) reduces the incidence of TD by approximately 50%. BSS should be avoided by travelers with aspirin allergy, renal insufficiency, and gout and by those taking anticoagulants, probenecid, or methotrexate. In travelers taking aspirin or salicylates for other reasons, the use of BSS may result in salicylate toxicity. BSS is not generally recommended for children aged <12 years.

At this time, prophylactic antibiotics should not be recommended for most travelers.

Prophylactic antibiotics afford no protection against nonbacterial pathogens and can remove normally protective microflora from the bowel, rendering a traveler more susceptible to infection with resistant bacterial pathogens.

Prophylactic antibiotics may be considered for short-term travelers who are high-risk hosts (such as those who are immunosuppressed) or who are taking critical trips during which

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even a short bout of diarrhea could affect the trip (18).

Lastly, there has been the realization that preventing illness in travelers is only part of the goal of travel medicine.

Travelers and the health care practitioners who advise them should consider the impact that a vacation, business venture, or service project has on the cultural, ecological, physical, and sexual health of the local population at the travel destination. (1) D. Compared toother countries According to America– United States Public Health Service recommendations in clinical guide, management of traveler’s diarrhea includes education and advice about prevention, food andliquid hygiene (A-III), and provision for prompt self-treatment in the event of illness (A-I). The elements of self-treatment include hydration; treatment with loperamide for control of symptoms, if necessary (when there is no temperature 138.50C or gross blood in the stool); and a short course (single dose to 3 days of therapy) of a fluoroquinolone antibiotic (A-I).

Antibiotic resistance of enteric pathogens, partic-ularly Campylobacter species, in the destination country needs to be considered. For those travelling to these destinations, as well as for other travelers, azithromycin may be indicated (B-II).

Combination treatment with loperamide and an antibiotic may be considered for travelers

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with moderately severe diarrhea(B-III).

Antibiotic prophylaxis is not recommended

particular about temporary blackening of the tongue and stool, and rarely ringing in the ears. Because of potential

for most travelers (A-III) (1).

adverse side effects, prophylactic bismuth subsalicylate should not be used for more than 3 weeks.

Some antibiotics administered in a once-a-day dose are 90% effective at preventing travelers' diarrhea; however, antibiotics are not recommended as prophylaxis.

Routine antimicrobial prophylaxis increases the traveler's risk for adverse reactions and for infections with resistant organisms. Because antimicrobials can increase a traveler 's susceptibility to resistant bacterial pathogens. As a result, strict adherence to preventive measures is encouraged, and bismuth subsalicylate should be used as an adjunct if prophylaxis is needed (20)

Table 1. Infectious Diseases Society of America–United States Public Health Service grading system for ranking recommendations in clinical guidelines (1).

CDC does not recommend antimicrobial drugs to prevent TD. Studies show a decrease in the incidence of TD with use of bismuth subsalicylate and with use of antimicrobial chemoprophylaxis.

Several studies show that bismuth subsalicylate taken as either 2 tablets 4 times daily or 2 fluid ounces 4 times daily reduces the incidence of travelers' diarrhea.

The mechanism of action appears to be both antibacterial and antisecretory. In addition, persons should be informed about potential side effects, in

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CONCLUSION Indonesia was time to have an agency that is moving in terms of disease traveler. So it can be made a standard knowledge inpreventive measures and early response if the traveler experience the disease. It is not impossible, if thes tandard or guidelineis a derivative of the health system which handles about public health or infectious diseases, so that the new agency is not required, only needed to form adivision. The guidelineis very necessary to the people who will travel to Indonesiain order to prepare for the risk factors that exist in the area.

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simple. The easy mnemonic to remember for traveler disease such as diarrhea is “Boil it, cook it, peel it, or forget it”. It’s very easy to remember and possible to do (17).Until now there has been no study of the prevention that has been done by the Indonesian government to issue travel diseases, especially diarrhea. Therefore our hope is this paper can be the trigger that the government must pay attention to health problems for the tourists, so the domestic and foreign travelers who came to Indonesia, will not go home with a disease.

REFERENCES

Prevention should not only be seen on one side, but prevention of traveler must be done to make improvements in a numberof health and hygiene figures in Indonesia it self,considering the high incidence of diarrhea disease in Indonesia, which is spread invarious provincesas well as the outbreak of diarrhea.

Therefore, Indonesia needs to make hygiene behavior indicators: Example of the house with access to clean water, restaurant with a healthy environment, and permitting for selling food and drink.

1.

As well as awareness about hand washing and hygiene practices and clean in Indonesia should be improved, since only 23.2% according Riskesdas population in Indonesia has a habit of washing hands properly. Not only us who do preventive measures but the government needs to make a regulation for this hygienity preventive efforts.

3.

Prevention of travelers’ diarrhea is important and keep it

2.

4.

David R. Hill, Charles D. Ericsson, Richard D. Pearson, Jay S. Keystone, David O. Freedman, Phyllis E. Kozarsky, Herbert L. DuPont, Frank J. Bia, Philip R. Fischer, and Edward T. Ryan. 2206.

The Practice of Travel Medicine: Guidelines by the Infectious Diseases Society of America. IDSA Guidelines : CID:43 Disease Emergence and Resurgence: The Wildlife– Human Connection. Zoonoses and Travel Ji Yong Ahn, Jin-Won Chung, Kyu-Jin Chang, Myung Hwan You, Jin Sung Chai, Young A Kang, Seong-Han Kim, Hyesook Jeoung, Doosung Cheon, Ahyong Jeoung, and Eun Suk Choi. 2011. Clinical Characteristics and Etiology of Travelers’ Diarrhea among Korean Travelers Visiting South-East Asia. J Korean Med Sci; 26: 196-200.

Disease Emergence and Resurgence: The Wildlife–

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Human Connection. Infectious diseases of potential risk for travellers Herbert L, Dupont. 2004.

Traveler's Diarrhea. Houston: Elsevier Journal of Travel Medicine.

2008.

Gastrointestinal complaints in Ill. Volume 15, Issue 4, 221–228 Kozicky et al., 1985. Int. J. Epidemiol; 14: 169-72 Kean BH. 1963. The diarrhea of travelers to Mexico: summary of five-year study.

Ann Intern Med; 59:605–14.

Gorbach SL, Kean BH, Evans DG, Evans DJ, Bessudo D. 1975. Travelers’ diarrhea and toxigenic Escherichia coli.

New Engl J Med; 292:933–6.

Merson MH, Morris GK, Sack DA, et al. 1976. Travelers’ diarrhea in Mexico: a prospective study of physicians and family members attending a congress. New Engl J Med; 294:1299–304.

Sack RB, Froehlich JL, Zulich AW, et al. 1979. Prophylactic doxycycline for travelers’ diarrhea: results of a prospective double-blind study of Peace Corps volunteers in Morocco.

Gastroenterology; 76:1368–73.

DuPont HL, Reves RR, Galindo E, Sullivan PS, Wood LV, Mendiola JG. 1982.

Treatment of travelers’ diarrhea with trimethoprim/sulfamethoxazole and with trimethoprim alone. New Engl J Med; 307:841–4.

Ericsson CD, DuPont HL, Mathewson J, West MS, Johnson PC, Bit-sura JAM.

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Treatment of traveler’s diarrhea with sulfamethoxazole and trimethoprim and loperamide. JAMA 1990; 263:257–61.

Adachi JA, Ericsson CD, Jiang ZD, et al. 2003. Azithromycin found to be comparable to levofloxacin for the treatment of US travelers with acute diarrhea acquired in Mexico.

Clin Infect Dis; 37:1165–71.

Steffen R, Sack DA, Riopel L, et al. 2006. Therapy of travelers’ diarrhea 1532 CID : 43 Departemen Kesehatan RI. 2009.

Profil Kesehatan Indonesia 2008. Jakarta : Departemen Kesehatan Republik Indonesia Anne McCarthy. 2000. Malaria and Travellers Diarrhea Manitoba 7th Travel Health Conference. Tropical Medicine and International Health Clinic Division of Infectious Diseases Ottawa Hospital General Campus, Ontario, Canada Connor, Bradley A. 2013.

Travelers’ Diarrhea. http://wwwnc.cdc.gov/travel/ye llowbook/2014/chapter-2-thepre-travelconsultation/travelers-diarrhea.

Accessed on January 15, 2014 Clinics Australia. 2012. Travel Health Fact Sheet : Indonesia. www.traveldoctor.com.au accesed on January 15,2014 CDC. 2006.

Traveler’s Diarrhea. http://www.cdc.gov/ncidod/db md/diseaseinfo/travelersdiarrhe a_g.htm accessed January 15, 2014

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PREVENTION OF TYPHOID FEVER AS TRAVELLER DISEASE: IMMUNIZATION AND HYGIENE PRECAUTION BY TRAVELLERS AND INDONESIAN PEOPLE Cindy Anastasia Liu, Maria Satya Paramitha, Jessica Universitas Indonesia, Jakarta

Introduction Typhoid fever is a water- and food-borne enteric bacterial infection that is potentially severe and occasionally lifethreatening. It is caused by Salmonella enterica serotype Typhi (S. typhi) and transmitted by the faecal-oral route.[1,2] Humans are the only natural host and reservoir of this disease. The disease occurs when the ingested bacteria survive in acidic gastric environment and then enter the small intestine where they invade and cross the intestinal epithelium and finally spread to spleen, liver, and bone marrow. The incubation period for typhoid is approximately 7-14 days, even though it may be as long as eight weeks. Typhoid fever usually takes place in patients with ages of 5-25. After the incubation period, bacteremia develops and the symptoms of fever, malaise, chills, nausea, anorexia, diarrhea, generalized abdominal pain, myalgia, a dull frontal headache, and nonproductive cough usually occur.[1,3]

As one of the countries in Southeast Asia, Indonesia is one of the regions with the highest incidence of enteric fever per year.[4] This finding is consistent to the result of another study conducted by Crump et al that also indicates Indonesia as one of the countries with high incidence of enteric fever. [5] According to a study in 2008, which involves five Asian countries, the annual indigenous typhoid incidence of Indonesia is 180,3 per 100.000 people.[6] Another study conducted by Tjipto BW, et al also stated that typhoid fever in Indonesia is still an endemic disease.[7] According to Riset Kesehatan Dasar 2007, prevalence of typhoid in Indonesia is 1,6% and several provinces in Indonesia, such as Gorontalo, Papua Barat and Papua, Sulawesi Selatan, Sulawesi Tengah, Nusa

Tenggara Barat, Nusa Tenggara Timur, Kalimantan Selatan, Kalimantan Timur, Bengkulu, Banten, Jawa Tengah, Jawa Barat, and Nanggroe Aceh Darussalam, even have higher prevalence than the national prevalence.

Figure 1. Geographic Distribution of Typhoid Fever[8]

In developed countries, enteric fever becomes a sporadic disease, which mainly occurs in returned travelers. The incidence of typhoid among travelers to the developing countries is approximately 330 cases per 100,000 travelers per year in overall.[4] As a developing country and an endemic country of typhoid, Indonesia contributes to typhoid cases occur in travellers from Indonesia.

Studies conducted in neighboring countries, such as Australia and Singapore, show that most of the typhoid cases were originated mainly from India and Indonesia. Out of 1917 isolates in Australia, the most common sources of acquisition is from India (33%) and Indonesia (22%)[9], while 75% of the 2464 confirmed cases of enteric fevers (1699 typhoid cases and 765 paratyphoid cases) in Singapore were imported mainly from India and Indonesia.[6] Besides, a 7-year study (19972003) conducted in Swedish citizens also shows that Indonesia is one of countries

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from which the patients with typhoid fever were infected.[10] Travellers who are visiting their relatives and friends are at increased risk of suffering from typhoid fever.[1]

Fortunately, the strains of S. typhi in Indonesia are susceptible to most of the first-line standard drugs.[11,9] Therefore, typhoid fever from Indonesia can be treated by using parenteral fluoroquinolone for a minimum of 10 days.[12] It is also stated that the administration of dexamethasone at an initial dose of 3 mg/kg intravenously over 30 minutes and then followed by 1 mg/kg every 6 hours for eight additional doses can lower mortality for 50% to 10% in Indonesian children and adults.[3] Besides, supportive measures, such as the use of antipyretics, oral or intravenous hydration, and appropriate nutrition and blood transfusions if necessary are important to manage the typhoid fever.[12]

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The facts that typhoid fever is endemic in Indonesia and infects travellers worldwide, the diagnosis that is difficult to be made due to the lack of sensitivity of the tests, and the complications that might be lifethreatening make the preventions for this disease becomes very important to be performed, especially for the travellers.[14] The preventions of typhoid fever have actually been quite well known, which is vaccination and hygiene precaution for both Indonesian citizens and the travellers,[1,15,16] since typhoid fever is strongly associated with personal hygiene and environmental sanitation.[7] However, even though these preventions have been well known since long time ago, the real actions of prevention are actually very low, especially in developing countries, including Indonesia (based on Riset Kesehatan Dasar 2007).[7] Therefore, it is really important to establish real actions in order to prevent this disease from occurring by now.[5]

Materials and Methods However, even though it is relatively easy to treat typhoid fever in Indonesia due to its susceptibility to fluoroquinolone, it is still relatively difficult to diagnose this disease. Blood culture, which is the gold standard to diagnose typhoid fever according to WHO[12], actually only has the sensitivity range of 40-80%.[13] Therefore, complications might occur as well. It is stated that complications occur in 10-15% of patients and are more likely to develop in patients with the disease for more than two weeks. The complications that might occur include serious complications, such gastrointestinal bleeding, intestinal perforation, and typhoid encephalopathy, or other complications, such as myocarditis, meningitis, hepatitis, bronchitis, focal abscess, miscarriage, pharyngitis, and pneumonia. Typhoid fever can also cause death.[3] According to Riset Kesehatan Dasar 2007, typhoid causes 1.6% death of all ages.

The aim of this study is to show the most effective preventions, which can be performed to reduce the transmission of typhoid fever as one of the most prominent travellers diseases in Indonesia. The method used by the team is study of literature, which involves several steps: 1) Reviewing the aspects, which are going to be discussed by the team.

2) Determining the keywords, which will be used throughout the study.

3) Obtaining updated theories and opinions from textbooks or journals based from the certain keywords.

4) Reviewing secondary analysis from researches related to the topic and keywords.

5) Making comparison of the results with the situation in Indonesia.

6) Determining the best solutions for the problem.

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Results

disease, including the travellers.

As it has been mentioned before, there are two preventions that can be performed to prevent the transmission of typhoid fever to the travellers. The first prevention is immunization and the second prevention is hygiene precaution. Both preventions have to be performed by both travellers and Indonesian people, including government, doctors, and the citizens.[1,15,16]

However, despite the importance of these vaccines in controlling this disease, they have not been implemented widely in developing countries, including in Indonesia.[7] In Indonesia, typhoid vaccine is still included in the Immunization Development Program that is just recommended, which means that government has not facilitated these vaccines freely.[7]According to the interview s and meetings with more than 160 policymakers in seven Asian countries, including Indonesia, one of the main reasons that the vaccines have not been widely implemented in endemic countries is cost.[18]

A. Immunization Currently, there are two types of vaccines available and recommended. The first type of vaccine is Vi vaccine. Vi vaccine, which contains Vi polysaccharide, is given in a single dose intramuscular or subcutaneous. Protection from this vaccine begins seven days after the injection, with maximum protection in day 28 after injection. This vaccine is approved for people with age over two years. For travellers, revaccination is recommended every three years. This vaccine is mainly used by travellers who visit areas with high risk of typhoid fever because of the presence of multidrug-resistant strains.[12] The second type of vaccine is the live oral vaccine Ty21a, which is available in the form of liquid formulation or entericcoated capsule and should be administered on an empty stomach in three doses two days apart. The protection starts 10-14 days after the third dose. This vaccine is approved for people with the age of more than 5 years. Revaccination should be done annually for the travellers.[12] According to WHO, immunization of both vaccines for school-age children is recommended in areas where the control of the disease is a priority [12] because these vaccines have the potential to reduce the burden of the diseases largely even among the poorest sub-populations worldwide.[17] Therefore, as an endemic area of typhoid fever, the government of Indonesia should establish the school-based typhoid immunization programs, and if possible, the community-based typhoid immunization program as well, to control the disease and reduce the risk of other healthy people to get infected by the

If the implementation of both vaccines is impossible for now, government can at least implement one of those vaccines first, which is Vi vaccine. It is because the administration of Vi vaccine is much easier, which is only in a single dose, in contrast to Ty21a that must be administered in at least 3 doses at precise every-other-day intervals. Besides, Vi is more thermostable than Ty21a. Thus, it is much easier to store the vaccines. Other than that, there has been evidence that the production technology for Vi vaccine could be transferred successfully to the producers in countries that are typhoidendemic.[5] Besides, a series of demonstration trial on Vi vaccination have been done and the vaccination program is found to be feasible in both community settings and schools and relatively inexpensive to deliver in several countries, including Indonesia.[16] Moreover, the protection level of this vaccine alone is also effective in controlling typhoid fever. A study in China shows that programmatic use of Vi vaccine alone in selected areas controlled the disease largely within a 4-5 years period by reducing the outbreaks and incidence to very low levels.[17] Other than that, WHO also recommends vaccination in travellers who are going to visit high-risk areas where the disease is endemic, including Indonesia.[12] Thereby,

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travellers who are going to Indonesia should also get vaccinated beforehand.

However, according to a study performed in US, out of 1027 patients who suffered from typhoid fever due to travelling abroad, only 36 (4%) of whom reported having received a vaccination.[19] Another evidence in Singapore stated that only 20% of Singapore travellers who had previously sought pre-travel advice, including the advice about vaccination, before travelling. Of note, the preferable destination of Singaporean travellers is Asia, including Indonesia.[6,20] These findings indicate that the implementation of typhoid vaccines in travellers is still low, and thus needs improvement as well.

However, vaccination alone against typhoid fever is not the correct method of prevention since the vaccines efficacy is only 50%-80%.

Indeed, dietary precautions as well as personal hygiene and improvement of sanitation by Indonesian resident, government, and doctors are the cornerstone to control typhoid fever. Meanwhile for travellers, dietary precautions and personal hygiene are really important and necessary to prevent the disease, even in individuals that have been vaccinated.[7,10,21] B. Hygiene Precaution According to a research conducted in Ujung Pandang (Sulawesi), it is shown that no use of soap for hand washing (OR=30) and consumption of street foods (OR=45) are two strong risk factors of typhoid fever.[22] Another study that is conducted in Semarang city and its surroundings demonstrates that the typhoid fever is associated with personal hygiene, poor housing, and inadequate food.[23] Meanwhile, according to a research conducted in Jakarta, the modifiable risk factors for typhoid fever are no use of soap for hand washing (OR, 1.91; 95% CI, 1.06-3.46), no latrine in the household (OR, 2.20; 95% CI, 1.06-4.55), sharing food from the same plate (OR, 1.93; 95% CI, 1.10-3.37), recent typhoid fever in the household (OR, 2.38; 95% CI, 1.03-5.48), and the use of ice cubes (OR, 2.27; 95% Cl, 1.31-3.93). Fecal

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contamination of drinking water is not associated with typhoid fever and no fecal carriers among food handlers in the households also found in this study.[2] These data shows that all distinctive routes of transmission of typhoid fever, such as spread by inadequate drinking water supply and sanitation, purchase of contaminated street foods, and person-toperson spread within households by poor personal hygiene can play a role in Indonesia.[11] Unfortunately, both the personal and environmental hygiene in Indonesia is very poor nationally. As it is shown in Table 1, for the personal hygiene, even though the national prevalence of the right behavior in defecation is 71.1%, the national prevalence of the right behavior in hand washing is only 23.2%. In this study, the behavior in defecation is defined as right if the person defecate in the latrine, while the behavior in hand washing is defined as right if the person washes his hands by using soap before eating, preparing foods, after defecating, after anal cleansing the child, and after touching or holding the animals.

Therefore, it is known that only 23.2% of Indonesian population washes their hands by using soap before and/or after doing those acts. Based on the Riset Kesehatan Dasar 2007, the percentage of people having right behavior in these fields are lower in rural than in urban.

Right

Wrong

Behavior in Defecating

71.1%

28.9%

Behavior in Hand Washing

23.2%

76.8%

Table 1. Indonesian Prevalence of Personal Hygiene Meanwhile for the environmental hygiene, Figure 2 shows that only 57.7% household nationally that has good access to clean water, while the other 42.3% household lacks access to clean water. Households in rural (51.3%) have less accesses to clean

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water than those in urban (67.9%).

Nationally, as can be seen in Figure 3, 21.7% household still uses drinking water from unreliable sources, such as unreliable well, unreliable water source, river water, and others. Besides, only 58.9% household use private latrine nationally. 24.8% household does not have latrine for defecating and 16.3% household uses public latrines. The national prevalence of household that has good sanitation access is only 43%, as it is shown in Figure 4. In this case, the good sanitation means that the household uses goose neck type of latrine. Moreover, on the Riset Kesehatan Dasar 2007, Figure 5 demonstrates that 32.5% household does not have wastewater disposal and more than 73% household does not have garbage disposal in the house.

Therefore, due to the poor level of hygiene in Indonesia, travellers have to maintain their own personal hygiene level high by frequently washing hand, other than

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having vaccination. Besides, avoiding food that has been stored and prepared under inadequate hygienic conditions, such as the food from the stalls on the streets, and avoiding raw food, shellfish, and ice from water that may be contaminated would also be wise to prevent typhoid fever. [1,7,10] Careless behaviors that shown by majority of Singaporean travellers that does not sought pre-travel advice, including medical information and travel health practice, and finally causing them to know nothing about dietary precautions and how to avoid diseases should also be eradicated, so that they would not suffer from typhoid fever.[6,20] Besides, people in Indonesia, including government, can also play a role in preventing the transmission of the disease by improving the availability of safe food and water and also the sanitation. A research shows that improving water quality at household level, as well as at the source, can actually reduce diarrhea significantly. Even though the evaluation of intervention is not the typhoid fever, it is likely that the interventions will have similar effects on the rates of typhoid fever. In urban areas, the treatment and control of the water supply system must be strengthened. At home, drinking water can be made safe by boiling it for one minute.

In rural areas, wells must be checked for the presence of pathogens and treated if necessary. Besides, fuel for boiling water and storage container may also have to be supplied. Besides, to improve the Conclusion In order to prevent typhoid disease from transmitted to the travellers who come to Indonesia, every group of people needs to cooperate together. First, Indonesian government should establish typhoid immunization programs of, at least, Vi vaccine, improve the sanitation and the availability of safe water and food, performing food safety inspections in restaurants and for the street food vendor activities, and also help raise public awareness on all the prevention measures

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sanitation, government should also provide appropriate facilities for human waste disposal for all community and collection and treatment of sewage.[12,15] Other than that, food safety is also a major factor in preventing the transmission of typhoid fever.

Appropriate food processing and handling must follow the basic hygiene measures, such as washing hands using soap before preparing food and avoiding raw food, ice, and also shellfish. Government can also play a role in ensuring the food safety by performing food safety inspections in restaurants and for street food vendor activities.[12] Besides, as humans are the only natural host and reservoir of this disease, the diagnosis and treatment of the S. Typhi carriers, especially the people who involved in food production, is also a good method to prevent typhoid fever from transmitted. In this method, doctors play an important role by performing the diagnosis and giving the treatments. This way has been proven to be effective in controlling typhoid fever before, even though in the low-incidence setting.[12,15] Moreover, health education to raise public awareness on all these prevention measures should also be performed by both doctors and government. It is because community involvement in typhoid prevention is really important to change their behavior regarding the hygiene and for setting up and maintenance of the necessary infrastructures.[12] by performing health education. Second, doctors in Indonesia, including us in the future, should also help achieving this goal by doing the right diagnosis and giving proper treatment for the S. Typhi carriers and also by promoting health education to the society. Third, Indonesian citizens can also contribute in preventing typhoid fever from transmitted to other healthy people, including the travellers, by participating in the typhoid immunization programs established by the government and also by maintaining proper personal hygiene and environmental sanitation as recommended by the doctors and also government. At last, the travellers should get vaccinated by

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typhoid vaccine before coming to Indonesia and while in Indonesia, they should also maintaining their own personal hygiene and taking dietary precaution. By performing these real actions, not only the travellers that would be free of typhoid fever, but also all of the citizens in Indonesia. At that time, the endemicity of typhoid fever in Indonesia will be reduced and therefore Indonesia will become healthier and safer for both the citizens and the travellers.

References: 1. Brunette GW. CDC Health Information for International Travel 2014: The Yellow Book. 1st ed. New York: Oxford University Press. 2014; p319-322.

2. Vollaard AM, Ali S, Widjaja S, et al. Risk Factors for Typhoid and Paratyphoid Fever in Jakarta, Indonesia.

JAMA 2004; 291:2607-2615.

3. Schofer JM. Reports: Typhoid Fever. The California Journal of Emergency Medicine 2005; 6(4):76-78.

4. Basnyat B, Maskey AP, Zimmerman MD, Murdoch DR. Enteric (Typhoid) Fever in Travelers. Clin Infect Dis. 2005; 41:1467-72.

5. Levine MM, Ferreccio C, Black RE, et al. Ty21a Live Oral Typhoid Vaccine and Prevention of Paratyphoid Fever Caused by Salmonella enterica Serovar Paratyphi B. Clin Infect Dis. 2007; 45:S24-8.

6. Ty AU. Ang GY, Ang LW, James L, Goh KT. Changing Epidemiology of Enteric Fevers in Singapore. Ann Acad Med Singapore 2010; 39:889-96.

7. Tjipto BW, Kristiana L, Ristrini.

KAJIAN FAKTOR PENGARUH TERHADAP PENYAKIT DEMAM TIFOID PADA BALITA INDONESIA. Buletin Penelitian Sistem Kesehatan 2009; 12(4):313-340.

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8. Crump JA, Luby SP, Mintz ED. The Global Burden of Typhoid Fever. Bulletin of the World Health Organization 2004; 82;346-353.

9. Commons RJ, McBryde E, Valcanis M, PPwling J, Street A, Hogg G. Twenty-six years of enteric fever in Australia: an epidemiological analysis of antibiotic resistance. Med J Aust 2012; 196(5): 332-336.

10. Ekdahl K, de Jong B, Andersson Y. Risk of Travel-Associated Typhoid and Paratyphoid Fevers in Various Regions. J Travel Med 2005; 12:197–204.

11. Vollaard AM. Typhoid and paratyphoid fever in Jakarta, Indonesia: Epidemiology and risk factors. Den Haag, Netherlands: Leiden University; 2004.

12. World Health Organization.

Background document: The diagnosis, treatment and prevention of typhoid fever.

Switzerland; 2003.

13. Bhutta ZA. Current concepts in the diagnosis and treatment of typhoid fever. BMJ 2006; 333:7882.

14. Smits HL. Limitations of typhoid fever diagnostic and the need for prevention.

Clin.

Vaccine Immunol. 2012; 19(11):18331837.

15. Crump JA, Mintz ED. Global Trends in Typhoid and Paratyphoid Fever. CID 2010; 50:241-246.

16. Whitaker JA, Franco-Paredes C, del Rio C, Edupuganti S. Rethinking Typhoid Fever Vaccines: Implications for Travelers and People Living in Highly Endemic Areas. Journal of Travel Medicine 2009; 16(1):4652.

17. Verma R, Bairwa M, Chawla S, Prinja S, Rajput M. New generation typhoid vaccines: An effective preventive strategy to control typhoid fever in developing countries. Human Vaccines 2011; 7(8):883-885.

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18. Deroeck D, et al. Policymakers’ views regarding the introduction of new-generation vaccines against typhoid fever, shigellosis and cholera in Asia. Vaccine 2005; 23:2762-74.

19. Steinberg EB, Bishop R, Haber P, et al. Typhoid Fever in Travelers: Who Should Be Targeted for Prevention? Clin Infect Dis. 2004; 39:186-91.

20. Lee VJ, Wilder-Smith A. Travel characteristics and health practices among travellers at the Traveller’s Health and Vaccination Clinic in Singapore. Ann Acad Med Singapore 2006; 35:667-73.

21. Papadimitropoulos V, Vergidis PI, Bliziotis I, Falagas ME.

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Vaccination against typhoid fever in travellers: a cost-effectiveness approach. Clin Microbiol Infect 2004; 10: 681–683.

22. Velema JP, van Wijnen G, Bult P, van Naerssen T, Jota S. Typhoid fever in Ujung Pandang, Indonesia – high-risk groups and high-risk behaviours. Tropical Medicine and International Health 1997; 2(11):1088-1094.

23. Gasem MH, Dolmans WMV, Keuter M, Djokomoeljanto R. Poor food hygiene and housing as risk factors for typhoid fever in Semarang, Indonesia. Tropical Medicine and International Health 2001; 6(6):484-490.

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FALCIVACC, A NOVEL INVENTION OF ADENOVIRUS 5-VECTORED PLASMODIUM FALCIPARUM VACCINE EXPRESSING CSP AND AMA1 COMBINED WITH HEPATITIS B VIRUS-LIKE PARTICLE (VLP) : BIOMOLECULAR APPROACH Matthew Billy, Arvin Pramudita, Gede Yuda Sugiarta Faculty of Medicine, University of Indonesia

Introduction Plasmodium falciparum is a protozoan species from Apicomplexa phylum. Its infection causes malaria with Anopheles sp mosquito as vector.

In 2012, WHO reports that approximately 627.000 peoples died from malaria, mostly children in Africa.1 In Indonesia, malaria is highly distributed in eastern part (provinces of Maluku, Nusa Tenggara Timur and Papua). Indonesian Ministry of Health reported that malaria outbreaks from 2006 until 2009 occurred predominantly in Kalimantan. The total malaria outbreak in 6 provinces with malaria endemic is 1,869 people and 11 people died with P. falciparum causing the largest encumbrance of this disease with a total of 86.4%.2 The symptoms of malaria are fever, chills, muscle pain, and diarrhea.

Among other plasmodium species, P. falciparum infection causes the commonest and most lethal of malaria.

This infection can lead to many complications, such as anemia, respiratory problem, shock, kidney failure, and cerebral malaria.3 Not little that the patient died because of this infection.2 For traveller, this disease has become the greatest issue because it can really hamper the trip into endemic area.

Nowadays, the drugs of choice for malaria are atavaquanone, doxycycline, and primaquine.

Atovaqoune is expensive especially for long duration trips and can not be taken by people who suffer renal

dysfunction. Doxycycline is suitable for last-minute travelers because it is started 1-2 days before traveling.

However, this medication must be continued until for 4 weeks after travel, thus, many travelers with shortduration trips would prefer not consume this. The last is primaquine, it is can not be used to patients who have glucose-6-phosphatase dehydrogenase (G6PD) deficiency.6 In short, there are so many side effects and drawbacks which emerged from those antimalaria drugs. For preventive treatment, conventional vaccine against P.falciparum infection has been proposed 30 years ago. However, this vaccine shows short-lived protection so it does not confer significant protection from falciparum malaria.3,4 Research conducted by Chuang et al,8 shows that a novel vaccine for P. falciparum infection has been developed. The non-replicating human serotype, adenovirus 5 vector (Ad) are inserted by gene encoding P. falciparum Circumsporozoite Protein (CSP) and Apical Membrane Antigen1 (AMA1). AMA1 create immunity against P. falciparum at erythrocytic phase, while CSP contribute at preerythrocytic phase. Although this vaccine offers multistage protection, its efficacy is still quite low due to its poor ability to induce antibody response. Antibody response is low and trend higher in the high dose group, but at the same time, T cell response gets lowered. The ideal one for vaccine is strong response in

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antibody and T cell responses in low dose.

Virus like particle (VLP) is a protein that mimics conformational structure of a virus, but, without its genome. Since VLP is lack of genetic material, it provides a safer alternative than attenuated virus. VLP is being developed as a potent and safe vaccine platform which can induce T cell and B cell responses. One of the best studied VLP is Hepatitis B (Hep B) VLP. Based on Kushnir review, Hep B can trigger T cell response and primarily antibody response.6 Based on those researches, author proposes a novel vaccine that combines Adenovirus 5-Vectored P. falciparum vaccine expressing CSP and AMA1 with Hep B VLP, with a name of Falcivacc. Hep B VLP will induce strong antibody response of this vaccine in a lower dose. Thus, increase its efficacy to protect from P. falciparum infection.

Material and Methods This paper is based on literature review primarily focused on biomolecular medicine. This study discuss about novel vaccine, NMRCM3V-Ad-PfCA which consist of Adenovirus 5-Vectored Plasmodium falciparum vaccine expressing CSP and AMA-1 protein. To increase its efficacy, this vaccine is combined with Hepatitis B Virus-Like Particle (VLP).

Production of vaccine. This vector is constructed using homologous recombinant system (Gen Vec’s Ad FAST technology) in E. coli to produce a recombinant Adenovirus with some deletions and insertions.

Production of CSP and AMA-1 are confirmed with Western blotting analysis. Finally, the construct are

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vialed in final formulation buffer (FFB) and loaded into single syringe prior to injection. Safety and tolerability assessment. Since it is the first clinical trial of this vaccine, the safety and tolerability to patients must be monitored. These characteristic can be shown in two different dose groups, lower dose and higher dose group.

Immunological endpoint : Enzyme Linked Immunosorbent Assays (ELISA). ELISA measures the total IgG antibody titer against CSP and AMA-1 protein. The sample from patient is added, diluted, incubated, and then measured with spectrophotometry.

Modified technique of ELISA, ELISpot is also performed in this experiment.6 Data collection in this study conducted by literature review from journal, scientific article, medical textbook, and internet pages. All references are sought for the latest update and improvement. Thus, the data and result of this study are valid and reliable. The data that is used in this study is secondary data so that it is called as literature review. Then, the data is come by through exposition, find the correlation between data, and analysis, presenting argument by logical thinking. After that, we find the conclusion to sum up.

Results Reports from Naval Medical Research Centre shows NMRC-M3VAd-PfCA administered as one intramuscular injection of 2×10!" particle units (pu) per dose (1×10!" pu each construct) had caused an increased responses of both CD4+ dan CD8+ T cells using ELISpot assay.

Four weeks after injection, subjects were challenged with P. falciparum sporozoites by mosquito bite, and the result: 4 from 15 (27%) were sterile

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protected. Antibodies responses by ELISA were low and thus making the vaccine efficacy quite low.6,8 VLP has been widely used as components of vaccine in trials. To date, a handful of VLP-based vaccines have been approved against hepatitis B virus (HBV) and human papilloma virus (HPV).9 Using HepB virus core particles as VLP-based vaccine against P. falciparum malaria (ICC-1132 vaccine) has been reported to increase IgG antibody response measured by ELISA.10 For safety and tolerability, the result shows that there is no any adverse events happening in low dose and high dose groups.

Falcivacc combines adenovirus 5-vectored vaccine ability to induce primarily T cell responses with Hep B VLP ability to induce antibody response. Using this combination, Falcivacc is a multi-stage vaccine against P. falciparum that can induce both cellular and humoral immunity to increase the potential efficacy of its predecessor.

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Figure 1. Kinetics of the IgG antibody response measured by ELISA using ICC-1132 (A), HBc protein without CSP inserts (B), and P. falciparum CS repeat peptide (C). Results are shown as GMT (Geometric mean titers) for all vaccines in the 50-µg dose (circles) and 20-µg dose (triangles) cohorts at various time points post vaccination (vaccinations are indicated by arrows)4 Discussion Plasmodium falciparum’s life cycle and patogenesis Plasmodium species can be further classified into P. falciparum, P. vivax, P. malariae, P. ovale, and P. knowlesi. Each species can cause different type of malaria. From this five species, P. falciparum causes commonest etiology for malaria and most lethal malaria. The life cycle and pathogenesis are not significantly different among species.1 Plasmodium infects human by the bite of mosquito carrying parasite from infected individual. This type of Plasmodium called as sporozoites, a mature form from oocytes. The sporozoites enter the bloodstream and then, liver. They infect hepatocytes and replicate there, producing schizont. Up to this pont, the parasite is in the preerythrocytic phase.11 These liver schizonts convert into merozoites and reenter the bloodstream. They invade red blood cells, digest hemoglobin, and multiply there. This causes RBC to burst and patient got malaria’s symptoms. This phase called as erythrocytic phase. 11

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Figure 3. Innate immune respone to falciparum malaria12 Figure 2. The Plasmodium11

life

cycle

of

The pathogenesis of malaria is tightly correlated to its life cycle. After infect hepatocytes, this parasite reenter the blood cell and wrap itself with host liver’s cell membrane, hiding from immune cell. And then, it invades the RBC and again, host immune cell can not recognize it.

Therefore, this parasite is invisible from host immune cell because most of its life cycle it resides within liver and blood cells.11

Immune response in P. falciparum’s infection Innate and adaptive immune responses contribute to control falciparum malarial infection. Innate immune responses to merozoites occur by stimulation of Toll-like receptors, namely TLR2, which binds parasite dsDNA. Once these receptors are stimulated they cause secretion of the pro-inflammatory cytokines IL-1, IL6 and TNF that cause fever, the hallmark of malaria infections.12

For adaptive immune response, it involves both humoral and cellmediated immune responses. Antibody against sporozoites is the first adaptive immune response designed to prevent the parasites reaching the liver. If they get to liver, CD8+ cytotoxic T lymphocytes will destroy infected hepatocytes via HLA class I antigen recognition within the liver. If this parasite can hide from immune cell in liver, it will convert to merozoite and reenter bloodstream. Antibodies to merozoites work by blocking infection of new erythrocytes. If the parasite has succeeded in infecting more and more erythrocytes, antibodies will attach on the surface of infected erythrocytes and bring about removal by phagocytosis, especially in the spleen. The final response is the formation of antibodies to gametocytes which block the development of parasites into the mosquito vector.12

Figure 4. Innate immune respone to falciparum malaria12

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Treatment of P. falciparum’s infection Treatment of malaria involves multi-drug regiments. Antimalarials commonly used include atavaquanone, chloroquine, doxycycline, mefloquine, and primaquine. Still, those antimalarial drugs have many drawbacks.

For prevention, the current method is to prevent mosquito bites and eliminate mosquitoes. There are not any licensed vaccines yet. Different approaches to produce new frontier in vaccine have been explored so far, but neither has fulfilled the criteria for being approved. 1,4,11 A Novel vaccine, NMRC-M3V-AdPfCA NMRC-M3V-Ad-PfCA (Naval Medical Research Center, multiantigen, multi-stage malaria vaccine, adenovirus serotype 5-vectored, P. falciparum CSP and AMA1 antigens) was first developed by the US Naval Medical Research Center.13 This vaccine use human adenovirus serotype 5 (Ad5) as a vector which is very potent in inducing immune response, especially CD8+ T cell activity. Cellular immunity, as well as humoral immunity, is a major component to obtain a protective effect of high efficacy against malaria as shown by experiments using irradiated sporozoites in animals.6,14 This vaccine combines Circumsporozoite Protein (CSP) pre-erythrocytic antigen with Apical Membrane Antigen 1 (AMA1) erythrocytic antigen, allowing multistage protection against malaria.15 Structure of vaccine This vaccine is a combination of two separate recombinant Ad5 constructs expressing the 3D7 strain of P. falciparum CSP (NMRC-MV-AdPfC) and AMA1 (NMRC-MV-AdPfA) as shown in figure 5. Both of

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them were codon-optimized for expression in mammalian cells. The parent adenovector was a serotype 5 adenovirus carrying deletion in E1, E4, and part of the E3 region with a transcriptionally inert spacer (TIS1) inserted into the site of the E4 deletion; resulting a replication defective vector.

CSP or AMA1 genes were inserted into the E1 region under the control of a cytomegalovirus promoter (hCMV IE).15 The two constructs were vialed separately and were mixed prior to intramuscular administration by needle as a single 1 mL deltoid injection at 2×10!" particle units (pu) per dose (1×10!" pu each construct).6

Figure 5. Schematic of Ad5-PfCSP and Ad5-PfAMA1 vectors6 Mechanism of action Adenoviruses are highly immunogenic. Ad5 (along with Ad1 and Ad2) usually cause general mild upper respiratory infections in children. They attach to host cell receptor, the Coxsackie adenovirus receptor (CAR), which is expressed on many cell types, including hepatocytes, the basolateral surface of epithelial cells, endothelial cells, myoblasts, and heart muscle cells. CAR also facilitates the entry into host cells. They activate the immune system presumably by expressing pathogen-associated molecular patterns (PAMPs), thus initiating production of proinflammatory cytokines and differentiation of immature dendritic cells into professional antigenpresenting cells.17

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CSP is expressed during the sporozoite and early liver stages of parasitic infection. This protein is involved in the adhesion of the sporozoite to the hepatocyte and invasion of the hepatocyte. Anti-CSP antibodies have been shown to inhibit parasite invasion and are also associated with a reduced risk of clinical malaria in some studies.18,19 The demonstrated protective role of vaccine induced anti-CSP responses and the fact that CSP is the predominant surface antigen of sporozoites, have made CSP the most popular antigen for use in preerythrocytic vaccine candidates.15 AMA1 is a erythrocytic or blood-stage antigen that aids in orienting the merozoite during invasion of erythrocytes and is also expressed during the sporozoite and hepatic stages.4 Studies shows that anti-AMA1 antibodies tend to be present in those who have acquired natural immunity to malaria and repeated natural exposure often leads to high titres of IgG to AMA1.15,20 NMRC-M3V-Ad-PfCA’s limitation : its poor ability to induce antibody response Even though it offers multistage protection against malaria, NMRC-M3V-Ad-PfCA has a relatively low efficacy, approximately 27% for sterile protection against P. falciparum malaria.6,16 Still, it is the highest protection achieved in humans against a parasite using a gene-based vaccine. The most advanced vaccine until now, the RTS,S/AS, has up to 51% protection – but limited only for pre-erythrocytic stage protection.15 The reason for NMRC-M3V-Ad-PfCA’s low efficacy is due to its poor ability to induce antibody response. Antibody response are low and trend higher in high dose group, but T cell response gets lowered, thus can not inhibit

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growth of cultured P. falciparum blood stage parasites.6,16 Virus-like particle Virus-like particle (VLP) is naturally-happening biodegradable nanomaterials that integrate viral features such as particulate structure, repetitive surfaces, but does not contain genetic information. VLP is being developed as a potent and safe vaccine platform which can induce T cell and B cell responses and can be produced in the large scale. VLP-based vaccines have been registered as prophylactic vaccine for Human papilloma virus (HPV) and Hepatitis B virus. Besides that, VLP also can be used to present foreign epitopes for immune system.21

Potency of VLP response inductor

as

antibody

Conventional vaccines contain adjuvant to modulate immune system by activating active innate immunity upon administration.

However, vaccines, made from advanced conjugation chemistry or recombinant DNA technology has permitted the field to move away from whole pathogen-based vaccines to recombinant subunit antigens.

VLP has been used as vaccine antigens for immunization against a plethora of diseases including HIV, enterovirus 71 (EV71), hepatitis B, HPV and influenza. VLPs are different from recombinant antigen in that they are particulate antigens. Antigen in particulate structure has been shown to be more immunogenic than standard soluble antigens. VLPs have also been established as a prominent to deliver non particulate heterologous antigens on their surface, via gene

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manipulation. This will improve antibody response due to multivalent presentation on the VLP surface, stimulating B cell interaction.21,22

Hepatitis B VLP proven to be effective in inducing antibody response Heb B VLP is VLP that mimics the structure of Hepatitis B virus. This type of VLP has been developed years ago. Multivalent antigen composed of repetitive epitope antigens like Hep B VLP can activate B cells response to produce massive antibodies at lower concentrations. Because the repetitive epitopes can induce crosslinking between B cell receptor, thus, creating a robust and vast induction. Many clinical studies have confirmed its effectiveness in inducing antibody response.23,24 So far, Heb B VLP has been approved by FDA and is currently commercialized worldwide, for instance GlaxoSmithKline's Engerix and Merck and Co Inc.'s Recombivax HB. 25

Figure 4. The schematic of Hep B VLP26

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Falcivacc, a novel vaccine that combine NMRC-M3V-Ad-PfCA and Hep B VLP With the addition of Heb B VLP, Falcivacc can eliminate the NMRCM3V-Ad-PfCA’s limitation in inducing antibody response. Now, this vaccine can induce T cell and antibody responses at the same time in lowdose. Hence, it can increase its protective ability. Also, this vaccine is efficient because of its single-dose injection. For cost issue, gene- based vaccine is cheaper that protein- based vaccine because it does not need to be expressed and Hep B VLP has been commercialized worldwide with a low cost.27 To sum up, Falcivacc can be a robust vaccine candidate to protect P. falciparum infection due to its high efficacy, efficiency (single dose), safety, and low cost.

Conclusions Through careful analysis of the latest available evidences, several conclusions can be made: 1. Falciparum infection causes the commonest and most lethal malaria. Furthermore, this type of malaria can complicate to other organ, such as brain, respiratory tract, and kidney.

Thus, preventing it to become outrageous is the best choice.

2. Conventional vaccine has been developed, but induces very little immune response.

Different approach has been developed to invent new frontier in vaccine. Still, neither has fulfilled the criteria for being clinically approved.

3. A novel vaccine, NMRC-M3VAd-PfCA - Adenovirus 5Vectored P. falciparum

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Vaccine Expressing CSP and AMA1, has been developed.

Safety test shows that there are not any adverse events. Its efficacy, undeniably, is the highest protection ever reached in humans against this infection for gene-based vaccine, but, it still need improvement because of its poor ability to induce strong antibody response.

4. VLP is protein particle that mimics the structure of virus, but without its genome. This particle induces T cell response and primarily antibody response.

5. Falcivacc, a novel vaccine that combine NMRC-M3V-AdPfCA and Hep B VLP. Hep B VLP can induce strong antibody response, thereby, maximizing the efficacy of NMRC-M3V-Ad-PfCA in low dose vaccine. This vaccine is promising candidate for P. falciparum infection due to its high efficacy, efficiency (single dose), safety, and low cost.

6. There should be further researches to test the efficacy and safety of Falcivacc in clinical study. Furthermore, researches to find the effective dose in human is also needed.

References 1. WHO . Malaria [Internet]. [updated 2013 Dec, cited 2014 Jan 7]. Available from: http://www.who.int/mediacentr e/factsheets/fs094/en/ 2. Departemen Kesehatan RI (DEPKES RI). Epidemiologi malaria di Indonesia. ISSN: 2088-270x.

Jakarta: Departemen Kesehatan RI; 2011

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3. Malaria symptoms [Internet]. [cited 2014 Jan 7]. Available from: http://www.nhs.uk/Conditions/ Malaria/Pages/Symptoms.aspx 4. Bremen JG. Daily J. Baron EL. Epidemiology, prevention, and control of malaria in endemic areas[Internet]. [cited 2014 Jan 7] Available on: http://www.uptodate.com/conte nts/epidemiology-preventionand-control-of-malaria-inendemic-areas 5. CDC. Choosing a drug to prevent malaria [Internet]. 2012 Nov [cited 2014 Jan 7] Available from: http://www.cdc.gov/malaria/tra velers/drugs.html 6. Chuang I, Sedegah M, Cicatelli S, Spring M, Polhemus M, Tamminga C, et al. DNA Prime/Adenovirus Boost Malaria Vaccine Encoding P. falciparum CSP and AMA1 Induces Sterile Protection Associated with Cell-Mediated Immunity. PLoS ONE. 2013 February; 8(2): p. 1-15.

7. Kushnir N. Streatfield SJ. Yusibov V. Virus-like particles as a highly efficient vaccine platform: Diversity of targets and production systems and advances in clinical development. Vaccine. 2012; 31(1): 58-83 8. Sedegah M, Tamminga C, McGrath S, House B, Geneshan H, Lejano J, et al.

Adenovirus 5-Vectored P. falciparum Vaccine Expressing CSP and AMA1. Part A: Safety and Immunogenicity in Seronegative Adults. PLos ONE. 2011 October; 6(10): p.

1-23.

9. Roldao A, Mellado MCM, Castilho LR, Carrondo MJ,

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Alves PM. Virus-like particles in vaccine development. Expert Rev Vaccines. 2010; 9(10): p.

1149-1157.

10. Nardin EH, Oliveira GA, Calvo-Calle JM, Wetzel K, Maier C, Birkett AJ, et al.

Phase I Testing of a Malaria Vaccine Composed of Hepatitis B Virus Core Particles Expressing Plasmodium falciparum Circumsporozoite Epitopes. Infect Immun. 2004 November; 72(11): p. 65196527.

11. CDC. Malaria [Internet]. [cited 2014 Jan 7]. Available from: http://www.cdc.gov/malaria/ab out/biology/ 12. Gray C. Mercer M. Loubser S. Kriel C. Malaria [Internet]. [cited 2014 Jan 18] .Available from: http://immunopaedia.org.za/ind ex.php?id=387 13. Hill AVS. Vaccines against malaria. Phil Trans R Soc B. 2011; 366: p. 2806-14.

14. Sandoval AR, Berthoud T, Alder N, Siani L, GIlbert SC, Nicosia A, et al. Prime-boost immunization with adenoviral and modified vaccine virus ankara vectors enhances the durability and polyfunctionality of protective malaria CD8+ Tcell responses. Infect Immun.

2010; 78(1): p. 145-53.

15. Schwartz L, Brown GV, Genton B, Moorthy VS. A review of malaria vaccine clinical projects based on the WHO rainbow table. Malar J. 2012; 11(11): p. 1-22.

16. Sedegah M, Tamminga C, McGrath S, House B, Geneshan H, Lejano J, et al.

Adenovirus 5-Vectored P. falciparum Vaccine Expressing CSP and AMA1. Part A: Safety

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and Immunogenicity in Seronegative Adults. PLos ONE. 2011 October; 6(10): p.

1-23.

17. Tatsis N, Ertl HCJ. Adenoviruses as vaccine vectors. Mol Ther. 2004 October; 10(4): p. 616-29.

18. John C, Tande A, Moorman A, Sumba P, Lanar D, Min X, et al.

Antibodies to preerythrocytic Plasmodium falciparum antigens and risk of clinical malaria in Kenyan children. J Infect Dis. 2008; 197: p. 519-26.

19. Cohen J, Nussenzweig V, Nussenzweig R, Vekemans J, Leach A. From the circumsporozoite protein to the RTS,S/AS candidate vaccine.

Hum Vaccin. 2009; 6: p. 90-6.

20. Courtin D, Oesterholt M, Huismans H, Kusi K, Milet J, Badaut C, et al. The quantity and quality of African children’s IgG responses to merozoite surface antigens reflect protection against Plasmodium falciparum malaria. PloS One. 2009; 4: p. e7590.

21. Brito LA, Malyala P, O’Hagan DT. Vaccine adjuvant formulations: a pharmaceutical perspective. Semin Immunol.

2013 Apr;25(2):130–45.

22. Kushnir N. Streatfield SJ. Yusibov V. Virus-like particles as a highly efficient vaccine platform: Diversity of targets and production systems and advances in clinical development. Vaccine. 2012; 31(1): 58-83 23. Sominskaya I, Skrastina D, Dislers A, Vasiljev D, Mihailova M, Ose V, et al.

Construction and

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Immunological Evaluation of Multivalent Hepatitis B Virus (HBV) Core Virus-Like Particles Carrying HBV and HCV Epitopes. Clin Vaccine Immunol.

2010 Jun 1;17(6):1027–33.

24. Vietheer PTK, Boo I, Drummer HE, Netter H-J. Immunizations with chimeric hepatitis B viruslike particles to induce potential anti-hepatitis C virus neutralizing antibodies. Antivir Ther (Lond). 2007;12(4):477– 87.

25. Roldão A, Mellado MCM, Castilho LR, Carrondo MJT, Alves PM. Virus-like particles in vaccine development. Expert

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Rev Vaccines.

Oct;9(10):1149–76.

2010

26. Bhusan A, Koehorst J, Sonnenberg L, Nitschel R, Elings W, Dammes N, et al.

Hepatitis B and the Hepatitis B core Antigen VLP [Internet]. [cited 2014 Jan 18]. Available from: http://2012.igem.org/Team:Wa geningen_UR/ModifyingtheHe patitisB 27. Science media center. DNA vaccine [Internet]. [cited 2014 Jan 18]. Available from: http://www.sciencemediacentre .org/wpcontent/uploads/2013/04/DNAvaccines.pdf

Figures

Figure 1. Kinetics of the IgG antibody response measured by ELISA using ICC1132 (A), HBc protein without CSP inserts (B), and P. falciparum CS repeat peptide (C). Results are shown as GMT (Geometric mean titers) for all vaccines in the 50-µg dose (circles) and 20-µg dose (triangles) cohorts at various time points post vaccination (vaccinations are indicated by arrows)4

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Figure 2. The life cycle of Plasmodium11

Figure 3. Innate immune respone to falciparum malaria12

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Figure 4. Innate immune respone to falciparum malaria12

Figure 5. Schematic of Ad5-PfCSP and Ad5-PfAMA1 vectors6

Figure 4. The schematic of Hep B VLP26

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A BIOMOLECULAR APPROACH OF CHIKUNGUNYA PREVENTION WITH COMBINATION OF CHIMERIC EASTERN EQUINE ENCEPHALITIS VIRUS (EEEV)/CHIKUNGUNYA VIRUS (CHIKV) AND INTERNAL RIBOSOME ENTRY SITE (IRES)-BASED ATTENUATION AS NOVEL VACCINE FOR CHIKUNGUNYA Ramadhan MIA, Wiyadharma LA, Wijaya E Universitas Indonesia Introduction Chikungunya fever is a neglected tropical disease caused by arboviral Chikungunya Virus (CHIKV), which belongs to family Togaviridae and genus Alphavirus.1 Mosquitoes from genus Aedes is the arboreal vector for CHIKV, especially Aedes aegypti and Aedes albopictus.2 Chikungunya is a self-limiting disease with some symptoms such as febrile illness, joint pain, vomiting, skin rash, and headache. There are only few cases of fatal morbidity and mortality as manifestation of chronic stage of Chikungunya, and these cases are associated with neurological disorders (meningoencephalitis, usually occurs in neonates), hemorrhagic manifestations (shock) and severe joint pain (which can turn into rheumatoid arthritis in elderly people).

Unfortunately, there is no treatment available for curing the disease; the treatments available are focused on curing its symptoms.3-5 Chikungunya was first identified in Tanzania in 1953. Since 2004, Chikungunya has reached epidemic proportions with substantial morbidity in African coast, Indian subcontinent, Southeast Asia and even starts to reach western hemisphere (Figure 1).3 Chikungunya is able to trigger a major outbreak in some areas due to urban cycle, which includes human-mosquito-human, as one of transmission methods of CHIKV (another method is sylvatic cycle

which includes primate-mosquitohuman).6 This outbreak sporadically appears but explosively affecting hundred to even thousand people.

CHIKV has different strain in every region and outbreak. In 2006, a new type of CHIKV caused major outbreak in Reunion, eastern Africa.4 One year after, the importation of CHIKV was detected in Italy and USA by Aedes albopictus as the main vector for those temperate areas.7,8

Figure 4. The dispersion of CHIKV in the world.3

In Indonesia, Chikungunya was first time identified as an outbreak in Yogyakarta and Jambi province in 1982, with seroprevalence number of 139, and disappeared 3 years later. But twenty years later, in 2001-2002, more massive outbreak, with seroprevalence number of 238, occurred in Aceh, South Sumatera, and West Java (Bandung, Cibitung and Bogor). There is also another outbreak in 2012-2013 within Central Java (Sragen, Purworejo and Brebes) with 24 cases and West Java (Depok) with 116 cases. Most of these cases occurred in female and middle-aged people.9-11 Center of

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Disease and Sanitation Control of Indonesian Ministry of Health predicts that Chikungunya still would be threat for public health in 2014.12 As mentioned before, there is no treatment available to eradicate Chikungunya. Therefore the control of disease is focused on preventing the disease transmission. Like other mosquito-borne viral disease, preventing the vector and contact between components in transmission are ineffective efforts.3 The best strategy to prevent Chikungunya is by vaccination. In spite of Chikungunya as an emerging disease and potency to be biological weapons, there is no licensed vaccine existed. A novel, low cost, effective, stabile, and practical vaccine is needed to reach the prevention target of Chikungunya.13 Once a live-attenuated vaccine candidate was developed and evaluated by the US Army in 1986, resulting a novel vaccine strain. Even though this vaccine is highly immunogenic in human, the reactogenicity of this vaccine is also high.14 Another trial of vaccine making with inactivated, DNA, and virus like particle vaccine are effective and having low-risky.15-17 However those vaccines need to be administrated more than once, which is impractical, high-costing, and unsuitable for developing countries.

Chimeric virus based vaccine by combining Alphavirus with Venezuelan Equine Encephalitis Virus (VEEV), Eastern Equine Encephalitis Virus (EEEV), and Sindbis virus is also effective and only need single dose, but it will undergo another reaction in mosquito vector.13,18 To overcome the stability in chimeric virus, there are some efforts to change the structure of this chimeric virus by addition and elimination.

Plante et al shows that the problem is

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sourced from subgenomic promoter of RNA. Thus, a modification of Internal Ribosome Entry Site (IRES) as one mechanism of promoting RNA transcription can be applied to modifying the structure of chimeric virus, resulted more effective and stabile vaccine.18 In this paper, we will evaluate the idea about combination of chimeric virus EEEV as the most effective chimeric virus with CHIKV and IRES modification to create effective and stabile Chikungunya vaccine.

Material and Methods This scientific paper is based on literature review with specialty in biomolecular medicine which discuss about the designation of Chikungunya vaccine based on chimeric virus with EEEV and IRES mechanism that will result in not only effective, high immunogenicity, stabile, and low-cost, but also practical by a single dose and do not infect the mosquitoes vector.

Production of recombinant chimeric EEEV/CHIKV. Firstly, IRES form Encephalomyocarditis Virus (EMCV) was amplified by RT-PCR using specific primer from VEEV resulting strain TC-83/IRES and then with PCRfusion techniques the strain joined with 3’ and 5’ terminus gene into EEEV/IRES. The strain later was cloned into a plasmid to replace promoter subgenomic RNA which had been inactivated by IRES.19 Finalization of infectious virus production. EEEV/IRES was purified, linearized, and added with a cap analogue to support RNA synthesis.

Next RNA was electroporated using gel electrophoresis technique into BHK-21 cells, and the final product of chimeric virus was collected under Cytopathic Effects (CPE) 18,19 mechanism.

Assessment of virus

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activities. Virus titers conducted by plaque assay in Vero cells with help from BHK-21 cells. Replication load of the virus was assessed also in Vero cells and C6/36 mosquito cells. RTPCR and agarose gel extraction technique was used to assess genetic stability. RT-PCR is also used to confirm that the chimeric virus was not replicating in mosquitoes vector.13,18,19 Data collection methods in this paper was conducted by literature review method regarding topic from some references including scientific article, medical student textbook, and journal (paper or website) which publication year was adapted based on information improvement. All of the data shown in this paper are valid and accounted. The data used was secondary data, including experiment and research result as well as article review. All the data collected then preserved into exposition (presenting data and fact to find the correlations of each other) and analysis (presenting argument by logical thinking). Finally, the conclusion about the topic would be taken.

Results CHIKV effect has been studied in lowcost animal model for human disease.

CHIKV was known to cause fatal encephalitis, myositis and myocarditis in newborn mice. To be further, CHIKV antigen were detected in 3-7 days in infected brain which underwent multifocal inflammation and necrosis in 5-week-old C57BL/6 mice.13,18 Another study in bonnet macaque (Macaca radiate) showed that viremia of CHIKV occurred in 6 days and did not develop symptoms. The viremia titer was up to 107 LD50/ml, with contribution of Aedes mosquitoes as vectors.6,13

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The major outbreaks of Chikungunya in some areas had generated some researches regarding CHIKV vaccines in 2000s until now.

Those researches used biomolecular approach in making an effective vaccine. These include chimeric virus, DNA vaccine, adenovirus vector, and virus like protein vaccine. All of them were successful in proofing immunogenicity against Chikungunya in human based on structural protein of CHIKV.15-17 However those vaccine models needed repeated use and had a great risk of instability and reversion.

Even DNA vaccine had not proven yet to be effective vaccination for Chikungunya.18 In 1986 US Army developed live attenuated vaccine called 181/clone 25 (181/25). This vaccine was made up from plaque-to-plaque MRC-5 cell culture passage of CHIKV wild-type strain, which was then attenuated in mice and macaques. The research produced one highly immunogenic Chikungunya vaccine for humans. However in phase II safety studies, 5 of 59 subjects suffered transient joint pain, presumably resulted from reversion of the vaccine due to its instability. No further explanations were available about detailed mechanism of the reversion.13,14 Chimeric virus vaccination with EEEV/CHIKV, VEEV/CHIKV, and Sindbis/CHIKV indicated promising hope as novel and effective prevention of Chikungunya. Study by Wang et al showed that all of the chimeric strains were seroconverted well in C57BL/6 mice. VEEV/CHIKV and EEEV/CHIKV, which were inoculated at doses from 3.8-5.9log10 PFU, appeared to be most immunogenic.

EEEV/CHIKV appeared to give lowest titer for the lowest dose (table).13 However, RT

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PCR tests showed that mosquito’s extraction showing significant number of residues.18 IRES-based mechanism was also implied in Chikungunya vaccination and caused no significant weight loss, footpad swellings, or other signs of the disease in 1.0 µl of a 104 PFU/ml doses. The mice with the strain received higher survival rate of CHIKV compared to others that not received. There is also no amplicons detected in RT-PCR. But IRES-based could not implement alone because of virus instability.18 Therefore, combining between chimeric virus EEEV/CHIKV and IRES-based mechanism would be an answer for CHIKV vaccination model.

Pandya et al showed that EEEV/IRES vaccination which given to 4-5-week-old NH Swiss mice with 104 triggered neutralizing antibodies, giving survival to all of the mice models with titers against it in the range of 160-640. None of the mice was detected to have viremia in first 3 days after immunization. Virus load in brain was also low with 2log10 PFU/g by plaque assay. This vaccine model was also stabile, proven by no nucleotide changes in sequence analysis but four minority mutations.

RCT-PR of homogenate extraction of mosquitoes exposed with chimeric virus showed no replication activity.19

Discussion CHIKV structure CHIKV is positive-charged RNA virus that belongs to family Togaviridae and genus Alphavirus. It is a single-strand RNA virus consist of ~11.8 kb RNA genome.20 The genome is capped and polyadenylated, encoding two open reading frames (ORFs). The ORF

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encodes four non-structural proteins (nsP1-4) for viral replication and five structural proteins (capsid, E1, E2, E3 and 6K) (Figure 2).21 Genomic and subgenomic RNA are produced in RNA replication, which functioning in different manner. Genomic RNA is responsible for producing nonstructural protein from 5’ ORF, whereas subgenomic RNA is responsible for producing structural protein. The virion comprises 240 heterodimers of E1/E2 arranged as trimeric spikes on the surface, which will be inserted into the plasma of infected cells in Chikungunya pathogenesis. To acquire virion envelope, 240 copies of capsid protein and genomic RNA are existing in its nucleocapsids.21-23

Figure 2. Structure of CHIKV.22

Chimeric virus and EEEV/CHIKV designation Chimeric virus is an artificial which combines two or more DNA or RNA fragments that contain at least two gene sequences from each fragment essential for replication from distinct viruses. Chimeric virus is considered to be a new method of vaccination production in which a hazard virus undergoes attenuation or even inactivation through combining of its gene and gene from other microorganism, making it may be a fewer hazard virus.24 Chimeric virus vaccine may be considered in preventing Chikungunya effort because if fragment from just one RNA that undergoes attenuation, it will have possibility to revert in vivo or endure compensatory mutation,

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which may re-adjust the attenuated virus to be virulent again as the 181/25 vaccine case.19,25 In that case, CHIKV underwent only 2 point mutations, which makes the vaccine was unstable.

To make a more stable vaccine, chimeric virus is applied by combining Chikungunya virus by fellow Alphavirus, in this occasion Equine Encephalitis Virus (EEV) such as VEEV, EEEV, and Sindbis Virus. This vaccine is gained by combining EEV strain as the backbone and CHIKV for its structural protein (Figure 3). EEEV was chosen as the main strain to be joined with CHIKV because it appeared to be most immunogenic and effective vaccine with low dose.13

period of viremia (7-8 days), followed by a whole immunity of Chikungunya.13

Internal Ribosome Entry Site (IRES) and EEEV/IRES designation

Figure 3. Schematic diagram of chimeric Encephalitis Virus/CHIKV vaccine candidates.13

EEEV/CHIKV was made using standard recombinant DNA methods.

Specific structural polyprotein-coding sequence was replaced with analogous CHIKV strain. Cis-acting RNA elements and nsPS, including 5’ and 3’ terminus and subgenomic promoter of EEEV are remained as the chimeric virus’ backbone. By combining these elements, lymphocyte B will recognize the surface of the chimeric virus as the antigen, but there is no chance for CHIKV to replicate because the nonstructural protein components were replaced by components from EEEV, in which using safer strain, for instance BeAr436087. This model will lead to give lower titers of virus and shorter

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Kozak et al and Konarska et al found that prokaryotic ribosomes could bind free circular RNA, which proposing that eukaryotic ribosomes enter mRNAs exclusively via free 5’ terminus.26,27 Later, Picornavirus was found to have a special structure in 5’ terminus non-translating region which allowed them to initiate translation, called Internal Ribosome Entry Site (IRES).28 IRES was first found in EMCV, and then defined as noncoding RNA fragment to initiate high-levels of cap-independent protein synthesis in infected cells. EMCV has two kinds of IRES, preferred IRES for usual condition (273-845 viral bases) and minimum IRES for minimum energy condition (400-836 viral bases).29 IRES in EMCV comprises multiple non-conserved AUG triplets upstream of the initiation codon, acting as strong barriers to scanning ribosomes so ribosomes can bind directly into it.

IRES mapping shows components eIF4A, eIF4E, eIF4G and PABP (Figure 4). To start the initiation, IRES needs 40S subunit to form 48S complexes which needs ATP and requires the same factors like 5’enddependent initiation plus recruitment for eIF4E, PABP, and N- and Cterminal fragments of eIF4G. eIF4A and central domain of eIF4G can replace cap-binding protein complex in cap-dependent initiation.30

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to replace 5’ untranslated region that synthesis promotion of EEEV structural proteins can occur (Figure 5). IRES sequence EMCV was chosen 19 This because its shorter structure.

EMCV IRES sequence cloning will impact to get no more residues from replicating EEEV in EEEV/CHIKV vaccines, so it has no chance at all to replicate and infect vector and, to be further, human because of the vector bites.

Figure 5. Schematic diagram of subgenomic structure of EEEV/IRES. The position of promoter is inside the box while mutations introduced is shown by lower case.19

Figure 4. Schematic diagram of human eIF4G1 protein which will bind into IRES (above)30 and the structure of IRES (below).29

Back again to EEEV/CHIKV vaccine, it was later found that EEEV/CHIKV can infect mosquito vector. This is because the residues remained had ability to infect the mosquitoes and attenuation was dependent to intact murine immune response by interferon.18 The main factors that cause this thing are 5’ and 3’ terminus and subgenomic promoter of EEEV that are still kept on persisted. Therefore, the subgenomic promoter of EEEV needs to be silenced or inactivated. One method that can be done to reach the aim is to using IRES mechanism to change EEEV/CHIKV into EEEV/IRES chimeric virus vaccine. Regarding to IRES mechanism, subgenomic promoter of EEEV from EEEV/CHIKV was inactivated by 16 analogous point mutations, which prevented virus reversion to be active subgenomic RNA promoter. The IRES sequence from EMCV was later cloned

Adaptation of chimeric EEEV/IRES in vector and host cells The main problem in implying virus component to build a vaccine is in vivo reversion potency of the virus. We have talked about this even earlier with exposition about 181/25 failure. From the case we know that finding the right vaccine for preventing Chikungunya is not an easy thing. Alphavirus has ability to accumulate adaptive mutations. Accumulation of those mutations will improve its positive charge by increasing virus binding to heparin sulfate, causing more efficient replication.31 In study regarding EEEV/CHIKV experiment, there were two mutations observed after three times passages to Vero cells: E150→K in E2 protein and nucleotide number 9 deletion.

The last mentioned contributes in increasing replication efficiency. These mutations were the origins of reactogenicity in mosquito cells. This data was supported by some heterogeneous in size of plaques after passage found in the experiment.13,19

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Meanwhile in EEEV/IRES experiment, it was discovered that the first passage of vaccine still lead to a little residues in Vero cells.

Nevertheless, there were no residues found afterwards. There were four minor mutations detected in Vero cells after EEEV/IRES insertion: D61→G, T72→K and Q194→R in E2 protein and S47→F in capsid. EEEV/IRES also left no residues in mosquito cells compared with FL93-939 vaccine that left ~700 bps residues. EEEV/IRES also gave slightly greater but still minimal swelling on mouse feet.19 Furthermore, viral load level in brain and spleen are detected low (discussed later).

Immunogenicity and efficacy EEEV/IRES in host cells

of

The immune mechanism about how CHIKV can cause illness in the body, including controlling of viral replication and dissemination, has still not known yet. However it is known that CHIKV antigen is also specific for CD8+ CTL and peptide pools.17 Furthermore, Kam et al found that Nterminus of E2 glycoprotein from CHIKV in Chikungunya fever patients’ plasma contains single linear epitope E2EP3, which is the dominant epitope as the target of human IgG, to be exact IgG3. This data supports findings that neutralizing antibodies (nAbs) have dominant roles in dealing with Alphavirus infection.32 Neutralizing epitopes of CHIKV have been plotted inside E1 as fusion protein and E2 as attachment protein in some Alphaviruses, including 33 CHIKV. Based Pandya et al, intracutaneous experimental

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seroconverted. The mice lost their weight, but recovered later in 7-8 days.

Symptoms of Chikungunya fever were not detected in mice after a week.

EEEV/IRES was not inducing viral reactogenicity in joints nor brain.

Histopathologic finding showed that viral load from EEEV/IRES in brain was below detection limit (< 2log10 PFU/g) compared with PBS/Shamvaccine. Moreover, there were no pathological signs in spleen after EEEV/IRES insertion compared with PSB-Sham vaccination in mice, which resulting splenic necrosis.13,19,34 Wang et al found that EEEV/IRES induced robust nAb titers by inoculating 3.8-5.9log10 PFU, which was the dose initiating uniformly robust titers (PRNT80 titers ≥ 20) and against reversion challenge. This response was gained directly after insertion of the vaccine (Figure 6). To make sure that immunity was from EEEV/IRES, there was also passive immune response test, in which some mice were given serum containing CHIKV antibody from EEEV/IRES. As a result, survival rate of these mice to Chikungunya infection was increasing, confirming the immunity was indeed from EEEV/IRES vaccine.

EEEV/IRES was confirmed to be made for general strains of CHIKV, recalling that only structural protein which was inserted in the vaccine model. This vaccine was safe and did not develop symptoms even with high-dose.13,34

on Wang et al and all EEEV/IRES given and subcutaneous to mice were fully

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Figure 6. Graphic of weight gain or loss in mice after vaccine insertion (above) and viremia period in mice after vaccine insertion (below). Both of the variable were compared with PBS/Sham-vaccination.18

Nevertheless, cellular immune response is also holding the key of deal with CHIKV as an antigen. Paessler et al found that Encephalitis Virus/CHIKV chimeric vaccine will not work well if the subject suffers alpha/beta TCR or interferon-gamma receptor alpha chain (R1)-chain deficiency.35 This finding indicates that EEEV/IRES induces cellular response as well as humoral response and both of them are required resolving Alphavirus infection, even though has not proven yet in human.

Conclusions There are some conclusions regarding the topic based on discussion above:

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and causes low morbidity and mortality, CHIKV can trigger major outbreak in urban cities.

Consequently, preventing CHIKV is an important consideration in global health issues. The best strategy to do so is by vaccination.

8. There were some efforts of creating candidates for Chikungunya vaccine: DNA vaccination, live-attenuated vaccination, Adenovirus vector, and virus like protein vaccine but the main problem was instability of the vaccines that resulting virus in vivo reversion. This reactogenicity problem can lead into more severe clinical manifestations and infection in vectors.

9. EEEV/IRES, which was developed from EEEV/CHIKV is a model of vaccine based on combination of chimeric virus to gain stability and Internal Ribosome Entry Site (IRES) in RNA translation to avoid infectiveness of the vaccine.

EEEV/IRES is a promising candidate for effective (stabile and high immunogenicity), safe, low-cost and practical Chikungunya vaccine.

10. There should be a clinical study of EEEV/CHIKV in humans to prove that this vaccine also has immunogenicity and stability in human host cells. Furthermore, research about effective dose and pharmacokinetic and pharmacodynamics of EEEV/CHIKV are also needed to be conducted in order to sharpen the advantages of this vaccine candidate.

7. Even though Chikungunya fever is a self-limiting disease

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References 28. Olivier S, Albert ML. Biology and pathogenesis of Chikungunya virus. Nat Rev Microbiol. 2010;8(7):491-500.

29. Dupont-Rouzeyrol M, Caro V, Guillaumot L, Vazeille M, D’Ortenzio E, Thiberge JM, et al. Chikungunya virus and the mosquito vector Aedes aegypti in the New Caledonia (South Pacific Region). Vector Borne Zoonotic Dis. 2012;12(12):1036-41.

30. World Health Organization.

Chikungunya fever: fact sheet [homepage on internet]. 2012 [updated 2014; cited 2014 Jan 19]. Available from: http://www.who.int/mediacentr e/factsheets/fs327/en/.

31. Borgherini G, Poubeau P, Staikowsky F, Lory M, Le Moullec N, Becquart JP, et al.

Outbreak of Chikungunya on Reunion Island: Early clinical and laboratory features in 157 adult patients. Clin Infect Dis. 2007;44(11):1401-7.

32. Manimunda SP, Mavalankar D, Bandyopadhyay T, Sugunan AP. Chikungunya epidemicrelated mortality. Epidemiol Infect. 2011;139(9):1410-2.

33. Higgs S, Ziegler SA. A nonhuman primate model of Chikungunya disease. J Clin Inves. 2010:120(3):657.

34. The Centers for Disease Control and Prevention. First reports of Chikungunya in western hemisphere [serial on internet]. 2013 [cited 2014 Jan 19]. Available from: http://www.cdc.gov/media/rele ases/2013/p1218chikungunyas.html.

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35. Rezza G, Nicoletti L, Angelini R, Romi R, Finarelli AC, Panning M, et al. Infection with Chikungunya virus in Italy: an outbreak in a temperate region.

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36. Wibowo. Sejarah Chikungunya di Indonesia, suatu penyakit reemerging? Med Litbang Kes. 2010:20;S55-8.

37. Dinas Kesehatan Jawa Tengah.

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Chikungunya di Depok [serial on internet]. 2012 [cited 2014 Jan 19]. Available from: http://www.depkes.go.id/index. php?vw=2&id=1764.

39. Kementerian Kesehatan Republik Indonesia. Penyakit 2014 [serial on internet]. 2014 [cited 2014 Jan 19]. Available from: http://www.depkes.go.id/index. php?vw=2&id=SNR.14010008.

40. Wang E, Volkova E, Adams AP, Forrester N, Xiao SY, Frolov I, et al. Chimeric alphavirus vaccine candidates for Chikungunya. Vaccine.

2008;26:5030-9.

41. Edelman R, Tacket CO, Wasserman SS, Bodison SA, Perry JG, Mangiafico JA. Phase II safety and immunogenicity study of live Chikungunya virus vaccine

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TSI-GSD-218. Am J Trop Med Hyg. 2000;62(6):681-5.

42. Wang D, Suhrbier A, PennNicholson A, Woraratanadharm J, Gardner J, Luo M, et al. A complex adenovirus vaccine against Chikungunya virus provides complete protection against viraemia and arthritis.

Vaccine. 2011; 29:2803-9.

43. Akahata W, Yang ZY, Andersen H, Sun S, Holdaway HA, Kong WP, et al. A viruslike particle vaccine for epidemic Chikungunya virus protects nonhuman primates against infection. Nat Med. 2010;16:334-8.

44. Mallilankaraman K, Shedlock DJ, Bao H, Kawalekar OU, Fagone P, Ramanathan AA, et al. A DNA vaccine against Chikungunya virus is protective in mice and induces neutralizing antibodies in mice and nonhuman primates. PLoS Negl Trop Dis. 2011;5:e928.

45. Plante K, Wang E, Partidos CD, Weger J, Gorchakov R, Tsetsarkin K, et al. Novel chikungunya vaccine candidate with an IRES-based attenuation and host range alteration mechanism. PLoS Pathog.

2011;7:e1002142.

46. Pandya J, Gorchakov R, Wang E, Leal G, Weaver SC. A vaccine candidate for eastern equine encephalitis virus based on IRES-mediated attenuation.

Vaccine. 2012;30(7):1276-82.

47. European Centre for Disease Prevention and Control.

Factsheet for health professionals: Chikungunya fever [serial on internet]. 2013 [cited 2014 Jan 20]. Available

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from: http://ecdc.europa.eu/en/healtht opics/chikungunya_fever/basic _facts/pages/factsheet_health_p rofessionals.aspx.

48. Sherman MB, Weaver SC. Structure of the recombinant Alphavirus Western Equine Encephalitis Virus revealed by cryoelectron microscopy. J Virol. 2010;84(19):9775-82.

49. Weaver SC, Osorio JE, Livengood JA, Chen R, Stinchcomb DT. Chikungunya virus and prospects for a vaccine. Expert Rev Vaccines.

2011;11(9):1087-1101.

50. Sun S, Xiang Y, Akahata W, Holdaway H, Pal P, Zhang X, et al. Structural analyses at pseudo atomic resolution of Chikungunya virus and antibodies show mechanisms of neutralization. eLife.

2013;2:e00435.

51. Kaufmann JK, Nettelbeck DM. Virus chimeras for gene therapy vaccination and oncolysis: adenoviruses and beyond. Trend Mol Med. 2012;18(7):265-76.

52. Gorkachov R, Wang E, Leal G, Forrester NL, Plante K, Rossi SL, et al. Attenuation of Chikungunya virus vaccine strain 181/clone 25 is determined by two amino acid substitutions in the E2 envelope glycoprotein. J Virol.

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53. Kozak M. Inability of circular mRNA to attach to eukaryotic ribosomes. Nat. 1979;280:82-5.

54. Konarska M, Filipowicz W, Domdey H, Gross HJ. Binding of ribosomes to linear and circular forms of the 5’-

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terminal leader fragment of tobacco-mosaic-virus RNA. Eur J Biochem. 1981;114:2217.

55. Basu A, Das P, Chaudhuri S, Bevilacqua E, Andrews J, Barik S, et al. Requirement of rRNA methylation for 80S ribosome assembly on a cohort of cellular Internal Ribosome Entry Sites. Mol Cell Biol.

2011;31(22):4482-99.

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in mice. Am Soc Microbiol.

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59. Kam YW, Lum FM, Teo TH, Lee WW, Simarmata D, Harjanto S. Early neutralizing IgG response to Chikungunya virus in infected patients targets a dominant linear epitope on the E2 glycoprotein. EMBO Mol Med. 2012;4(4):330-43.

56. Bochkov YA, Palmenberg AC. Translational efficiency of EMCV IRES in bicistronic vectors is dependent upon IRES sequence and gene location. Biotech.

2006:41(3):283.

60. Selvarajah S, Sexton NR, Kahle KM, Fong RH, Mattia KA, Gardner J, et al. A neutralizing monoclonal antibody targeting the acidsensitive region in Chikungunya virus E2 protects from disease. PLoS Negl Trop Dis. 2013;7(9):e2423.

57. Shatsky IN, Dmitriev SE, Terenin IM, Andreev DE. Capand IRES-independent scanning mechanism of translation initiation as an alternative to the concept of cellular IRESs. Mol Cells. 2010;30:4:285-293.

61. Wang E, Kim DY, Weaver SC, Frolov L. Chimeric Chikungunya viruses are nonpathogenetic in highly sensitive mouse models but efficiently induce a protective immune response. J Virol.

2011;85:9249-52.

58. Gardner CL, Choi-Nurvitadhi J, Sun C, Bayer A, Hritz J, Ryman KD, et al. Natural variation in the heparan sulfate binding domain of the eastern equine encephalitis virus E2 glycoprotein alters interactions with cell surfaces and virulence

62. Paessler S, Yun NE, Judy BM, Dziuba N, Zacks MA, Grund AH, et al. Alpha-beta T cells provide protection against lethal encephalitis in the murine model of VEEV infection.

Virol.

2007;367(2)”307-23.

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Figures and Tables

Figure 1. The dispersion of CHIKV in the world.3

Figure 2. Structure of CHIKV.22

Figure 3. Schematic diagram of chimeric Encephalitis Virus/CHIKV vaccine candidates.13

Figure 4. Schematic diagram of human eIF4G1 protein which will bind into IRES (above)30 and the structure of IRES (below).29

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Figure 5. Schematic diagram of subgenomic structure of EEEV/IRES. The position of promoter is inside the box while mutations introduced is shown by lower case.19

Figure 6. Graphic of weight gain or loss in mice after vaccine insertion (above) and viremia period in mice after vaccine insertion (below). Both of the variable were compared with PBS/Sham-vaccination.18

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EATING BEHAVIOUR OF STREET FOOD AS RISK FACTOR OF TYPHOID FEVER IN SURAKARTA Imasari Aryani, Aninditya Verinda Putrinadia, Kevin Wahyudy Prasetyo

Faculty of Medicine, Universitas Sebelas Maret

INTRODUCTION Typhoid fever is an endemic disease that has become a major public health problem in the tropic and subtropic developing countries. In 2000, it was estimated that over 2.16 million episodes of typhoid occurred worldwide, resulting in 216,000 deaths, and more than 90% of this morbidity and mortality occurred in Asia (WHO, 2008)[1]. In Asian countries, the evidence revealed annual typhoid incidence rate as high as 900/100,000 (Ochiai, Acosta, Holliday, et al., 2008)[2]. Typhoid fever is caused

by Salmonella typhi bacterial infection which is transmitted through ingestion with 8-14 days of incubation period.

Salmonella typhi enters the human body from contaminated food. Then it invades the gut mucosa in the terminal ileum through specialised antigensampling cells, known as M cells, which overlies gut-associated tissue, through enterocytes, or via paracellular route. The bacterium adheres to the intestinal mucosa in the terminal ileum through interaction with an epithelial receptor. The bacterium reaches the intestinal lymphoid tissue, and is drained into mesenteric nodes, the thoracic duct and the systemic circulation. The primary bacteraemia reaches the liver, spleen, and other reticuloendothelial system within 24 hours of their ingestion. The bacterium turns back into the bloodstream, named secondary bacteraemia, is the sign of clinical onset of the disease (Hadisaputro, 2012)[3]. The patients show some early symptoms such as high fever with “step ladder” pattern,

fatigue, abdominal pain, and some will develop a “rose spots” rash (Linda and Jatin, 2011)[4].

Several epidemiologic studies suggest either waterborne or foodborne transmission as the risk factors for typhoid fever which occurs in approximately 5% of infected persons (CDC, 2013)[5]. Typhoid fever is transmitted through ingestion of food or water contaminated by excreta of patients and asymptomatic carriers.

Therefore, it most common occurs in areas with poor water, poor hygiene practices, and poor sanitation system.

Environmental and behavioral risk factors that are independently associated with typhoid fever include consumption of street food (Carlos, 2011) [6].

The term “street food” refers to a wide variety of ready-to-eat foods and beverages sold, and sometimes prepared, in public places (WHO, 2002)[7]. The consumption of street food is common in developing countries. About 2.5 billion people eat street food everyday world-wide (FAO, 2007)[8]. The place of food preparation, cooking utensils, time and temperature abuse of cooked foods and the personal hygiene of vendors are the sources contributing to microbial contamination, including Salmonella (Rane, 2011)[9]. The preparation and storage place is not always clean and not far from source of contamination such as liquid drainage, wastewater and garbage disposal that act as media for growth of microorganisms [9]. The hygienic aspects of vending operation are major sources of concern for food

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control officers. Toilets and adequate washing facilities are rarely available.

The washing of hands, utensils, and dishes are often done in buckets or bowls [6]. The immersion of soiled or faecal contaminated hands in dishwater, rarely use of soap and detergent, and the infrequent water refilling of buckets are the factors that may create favourable conditions for survival of pathogens in dishwater and on dishes (Vollaard, Ali, Asten, et al., 2004)[10]. Poor hygiene of street vendors, in combination with faecal carriage of enteric pathogens including S. typhi, may help to explain the association between purchasing street food and foodborne illness, in particular Salmonella infections.

Although the street food-vendors are aware of transmission factors, their knowledge is not applied to foodhandling practice because of financial reasons [10].

The reason of conducting this study is because typhoid fever is a common travel disease in developing countries including Indonesia.

Moreover, many places in Indonesia can be found providing food without proper hygiene level. This condition contributes to the transmission of many pathogens such as Salmonella typhi, which becomes the cause of typhoid fever.

MATERIALS AND METHOD This study uses case control design to collect data needed, because the authors determined the samples based on the illness status of typhoid fever. The samples taken were people who live in Surakarta city, which were chosen by fixed disease sampling method. The authors determined the minimum number of samples by using the formula 15 x n (with n is the sum of independent variable and confounding factors) (Murti, 2006)[11].

The total sample used in this study is

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60 people consist of 30 people who have suffered from typhoid fever on November 2013, December 2013, and January 2014 as case sample and 30 who did not as control sample. The control sample also performed the eating behaviour in 2013.

The inclusion criterion in this study is people who live in Surakarta.

They are then compared according to their eating behaviour of street food, which is a risk factor for typhoid fever disease. The operational definition of eating behaviour of street food is that the respondents should at least once a week have meals on street food [12].

The dependent variable in this study is typhoid fever. Eating behaviour of street food acts as the independent variable of this study. This study uses family economic status as confounding factors to decrease the bias result of this study.

The authors conducted this study by having interview to several people in Surakarta city. Before getting the data, an informed consent was given to the each sample of research.

The interview was done by giving a set of questionnaires to the samples that included questions about the history of typhoid fever disease status (in the specified time of November 2013, December 2013, and January 2014), economic status, and hygienic aspects of eating place.

After the data was collected, it was then analysed by using SPSS programme to find the correlation between the risk factors and typhoid fever disease. The power of correlation can be measured quantitatively by logistic regression method. This test can show the Odds Ratio (OR) as the power of correlation that describes how much the risk factor can contribute to the incidence of disease.

Chi square test is used to find out whether the data obtained is statistically significant; it was

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measured quantitatively by binomial logistic regression test.

It is shown that amongst 60 respondents, 33 people have high economic status based on standard monthly salary in Surakarta, while the other 27 people are recorded to have low economic status (Table 3).

RESULTS The research has been conducted from on January 2014. The researchers took the data from the respondents who are the live in Surakarta city. Here is the result of this research: A. Distribution of Sample The respondents used in this research consist of 30 typhoid fever patients as the case sample and 30 non-typhoid fever patients as control sample (Table 1).

Table 1. Sample distribution based on patients’ status Patients’ Frequency status typhoid fever 30 non typhoid 30 fever Total 60 Table 2. Sample distribution based on eating behaviour of street food eating Frequency behaviour of street food positive 23 negative 37 Total 60 Table 2 shows that 23 respondents have eating behaviour of street food, whereas 37 respondents don’t have habit to consume street food.

Table 3. Sample distribution based on economic status Economic Frequency status High 33 Low 27 Total 60

20 15 10 5

Available

0

Not Available Hygiene trash waste of can disposal eaLng facility facility place

Figure 1. Hygiene level of Food Places From 23 respondents having street food, the authors found out 18 of them bought food in less hygiene eating place and only 5 bought food from hygiene eating place. Based on trash can facility, only 8 respondents bought food from vendors providing trash can when the rest 15 did not. Amongst of them, 14 respondents bought food from place without waste disposal facility (Figure 1).

B. Result of Data Analysis This research uses binomial logistic regression model test to analyze the collected data. This type of analysis is used to acknowledge the power of correlation between variables used in a research. Nevertheless, the authors have used Chi Square test to identify whether the data is statistically significant before using the regression test. The analysis is done by using SPSS programme.

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Typhoid Frequency based on eating fever status behaviour of street food

P

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high economic status respondents, get typhoid fever disease. The p value for economic status is also < 0.05.

Table 6. Binomial logistic regression test’s result

positive

positive 18

negative

5

negative 12

0.001

Table 4. Chi Square test between eating behaviour of street food and typhoid fever status The data presents that from 30 typhoid fever patients, 18 respondents have eating behaviour of street food while the other 12 respondents do not.

Five out of thirty people who don’t get typhoid fever have eating behaviour of street food. Chi Square test for eating behaviour of street food variable results in p value 0.001, which means that the data is statistically significant since p value < 0.05 (Table 4).

Table 5. Chi Square test between economic status and typhoid fever status

positive Negative

22 11

8 19

OR

eating 5.40 behaviour of street food

25

Typhoid Frequency based fever status on economic status Low high

Variables

P

0.004

Table 5 shows that from 33 respondents categorized having low income, 22 of them have positive status of typhoid fever. Whereas, 8 out of 27

economic status

1.58

CI 95% Lower Upper 1.08 26.93

0.35

7.17

The binomial logistic regression test shows that Odds Ratio (OR) for eating behaviour of street food variable is 5.40, which means that people who have eating behaviour of street food get 5.4 times bigger risk having typhoid fever. The value of OR for economic status variable is bigger than 1 too, therefore it is also a risk factor for getting typhoid fever. The value of Confidence Interval (CI) 95% for eating behaviour of street food variable is 1.08 until 26.93. It describes that people having eating behaviour of street food can get risk 1.08 until 26.93 times to get typhoid fever. Meanwhile, CI 95% value for economic status ranges from 0.35 to 7.17 (Table 6).

DISCUSSION According to the result that has been analysed, eating behaviour of street food can contribute as a risk factor of typhoid fever. Statistically, the data we found has p value of 0.001.

It means that the data is statistically significant. The binomial logistic regression test’s result shows that Odds Ratio (OR) for eating behaviour of

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street food variable is 5.40, which means that people who have eating behaviour of street food get 5.4 times bigger risk having typhoid fever. The value of Confidence Interval (CI) 95% for eating behaviour of street food variable is 1.08 until 26.93. It describes that people having eating behaviour of street food can get risk 1.08 until 26.93 times to get typhoid fever. Hussein G, et al 2001 made a research using case control study with 75 respondents and found that typhoid fever risk may increase 3.0 times greater on people eating food purchased from street vendors at least once in a week.

Statistically, the data has p value of 0.033 and CI 95% value 1.09-8.25.

Eating food purchased from street vendors become a risk factor for having typhoid fever because in Indonesia, street food vendors do not have easy access to potable water and good sanitation. Moreover, they do not have any health permits [12].

The result of this research is supported by our findings about the hygienic level of street food places from which our respondents bought their food. According to 23 respondents having street food, it was found that 18 of them bought food in less hygiene eating places and only 5 bought food from proper hygiene eating places. Based on trash can facility, only 8 respondents bought food from vendors providing trash can when the rest 15 did not. Amongst of the 23, 14 respondents bought food from places without waste disposal facility.

In order to decrease bias in this study we also observed the economic status of the respondents. Our results are consistent to the theory we obtained, that low economic status can increase the risk of typhoid fever. It is shown that statistically, the data collected is significant as p value is 0.004. Odds Ratio (OR) for economic

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status variable is 1.58, which shows that people with low income got 1.58 times bigger risk of having typhoid fever. Our result is in line with casecontrol study conducted by Nurvina WA, 2013. According to that study, the p value is obtained 0.016. It mentions people with low income can increase the risk of typhoid fever 8.8 times [13].

There are possible mechanisms of how low income may increase the risk of typhoid fever. Socioeconomic status determines healthy behaviour due to the social pressure or needs priority factors besides health consideration; it is the reason why some diseases are more common in people with low economic status (Maria HH and Lannywati Ghani, 2007)[14]. Money can be used to obtain health care and environmental improvements that help to prevent disease. According to Srikandi Fardiaz (2001), producing, processing, distributing, preparing, and consuming of food system is related to income and development of socioeconomic characteristic in people [15] . Food contamination by micro bacterial pathogens is caused by the use of unqualified water, improper waste disposal, poor hygiene and unsanitary food preparation, or low cleanliness level of the vendor.

This study may be bias due to the retrospective method that the respondents might mistake recalling their memory regarding to their history of eating behaviour of street food when they filled the questionnaires. This study is also weak as case-control study because of its small number of samples, so this study may not be representative enough to be applied for big population. In addition, the authors also did not control other confounding factors and thus may cause more bias to the result.

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CONCLUSION People who have aating behaviour of street food may increase the risk of typhoid fever 5.40 bigger than those who don't (OR = 5.40; p = 0.001). Low economic status used as confounding factor can also increase the risk for getting typhoid fever (OR = 1.58; p = 0.004).

REFERENCES 1. WHO. A study of typhoid fever in five Asian countries: disease burden and implications for controls. [Online]. 2008 [cited 2014 Jan 12]. Available from: URL: www.who.int/bulletin/voolumes/8 6/4/06-039818/en/ 2.

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RL Ochiai, CJ Acosta, MC Danovaro-Holliday.

A multicenter, population-based, prospective surveillance study of typhoid fever in 5 asians countries: disease burden and implications for control. Bull World Health Organ 2008 Apr; 86:260-268.

Soeharyo H. Current treatment of typhoid fever. In: Soeharyo H, Budi R, Muhammad HG, Muchllis AUS, Nur F, editors. Infectious Disease Challenges Now and Future; 2002 May 26-27; Semarang, Indonesia. Semarang: Badan Penerbit Universitas Diponegoro; 2002. p. 12.

Linda JV, Jantin MV. A.D.A.M. Health guide : enteric fever.

[Online]. 2011 [cited 2014 Jan 12]. Available from: URL: http://www.nytimes.com/health/gu ides/disease/typhoidfever/overview.html CDC. Typhoid fever.

[Online].2013 [cited 2014 Jan 13].

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Available from : URL: www.cdc.gov/nczved/divisions/df bmd/diseases/typhoid_fever/techni cal.html#incidence 6.

Carlos AG, Refugio TV, Angelica VL, Javier CR. Salmonella-a dangerous foodborne pathogen. In: Barakat SMM, editor. Croatia: InTech; 2012. p. 21-47.

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Patience M, Dorothy YM, Kwaku OD, Anthony A. Street food in accra, ghana. Bulletin of The World Health Organization 2002;80(7):546-554.

8.

FAO. School kids and street food.

[Online]. 2007 [cited 2014 Jan 13]. Available from: URL: www.fao.org/ag/magazine/0702sp 1.html

9.

Rane S.Street Vended Food in Developing World: Hazard Analyses. Indian J Microbiol 2011 Jan 1;51(1):100–106.

10. Vollaard AM, Ali S, Asten HAGH, Ismid IS, Widjaja S, Visser LG, Surjadi C, van Dissel JT. Risk factors for transmission of foodborne illness in restaurants and street vendors in Jakarta, Indonesia.

Epidemiol Infect 2004;132:863–872.

11. Murti B. Desain dan Ukuran Sampel untuk Penelitian Kuantitatif dan Kualitatif di Bidang Kesehatan. Yogyakarta: Gadjah Mada University Press; 2006.

12. Hussein G, Dolmans WMV, Keuter M, Djokomoeljanto R. Poor food hygiene and housing as risk factors for typhoid fever in semarang, indonesia. Tropical

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Medicine and International Health 2001 Jun;6(6):484-490.

13. Artanti NW, Zainafree I, Wahyono B. Hubungan antara sanitasi lingkungan, higienitas perorangan, dan karakteristik individu dengan kejadian demam tifoid di wilayah kerja puskesmas kedungmundu kota semarang tahun 2012. Fakultas Ilmu Keolahragaan Universitas Negeri Semarang 2013.

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14. Herawati MH, Ghani L. Hubungan faktor determinan dengan kejadian demam tifoid di indonesia tahun 2007. Media Penelitian dan Pengembangan Kesehatan 2007; 09(4): 165-173.

15. Fardiaz S. Pangan dan Gizi Bogor.

Jakarta, Indonesia: Sagung Seto; 2001

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Scientific Poster

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Public Poster

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AMSA UKI A lot of people has hobby to hike mountains.

Hiking is enjoyed by young people as well as ageing people although it is risky. But , why is it risky ? Because hiking can cause a wide variety of disease. One of them being Acute Mountain Sickness. Acute Mountain Sickness is on illness that can affect mountain climbers,hikers,skiers,or travelers at high altitudes, usually 8000 feet ( 2400 meters). Acute Mountain Sickness is cause by reducer air pressure and lower levels at high altitudes. We must know symptoms of mild to moderate acute mountain, it's include difficulty sleeping, headache, vomiting,etc.

Acute Mountain Sickness is easier to treat in the early stages.People with severe mountain sickness may need to be admitted to a hospital. If someone have fluid in his/her lungs ( pulmonary edema ), treatment may include oxygen , a high blood pressure medicine called nifedipine, beta agonist inhalers to open the airways, etc. Keys to preventing Acute Mountain Sickness include drink plenty of fluids, avoid alcohol, eat regular meals high in carbohydrates.

Don’t Let Your Trip Get Bitten Unika Atma Jaya, Jakarta Natasha Vinita Wardoyo, Fidia Tania In this era, human’s life is greatly enhanced by globalization. People can easily get everything they want without using lots of energy. For instance, the discovery and improvement of more sophisticated transportation means such as aero planes, trains, ships, and motor vehicles has helped people move easily in large numbers from time to time.

Nowadays, countries (including Indonesia) compete to promote their tourism. People start to notice that resources in Indonesia have a big potential to be explored. The unique cultures, the beautiful views, delicious foods, and friendly people make a lot of business partners on a global scale.

More and more visitors start to come to Indonesia. They are not aware of some threatening dangers. Some foreigners are more concerned with common risks like being robbed, got stuck in a middle of a natural disaster, being stranded and lost, and many more. This is often fatal as they are usually not prepared to face local diseases. Diseases associated with tiny creatures called mosquitos.

Countries such as Indonesia is prone to tropical infections such as malaria, especially in rural areas. Malaria is a mosquito-borne disease. People with malaria often experience fever, chills, and flu-like illness. If left untreated, they may develop severe complications and die. The World Health Organization estimates that in 2010 malaria caused 219 million clinical episodes and 660.000 deaths.

For everyone who wants to explore Indonesia, they better be prepared to protect themselves against malaria. Preventive actions can be taken, for example; taking malaria pills, use insect repellent, and basically to avoid mosquito’s bites by wearing long-sleeved clothing and bed net. So, do not let your trip get bitten, cheers and enjoy Indonesia!

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Tuberculosis :Unika Atma Jaya, Jakarta Michelle Oswari, Monika Aprilyanti, Santika Henny

Indonesia is located between the Indian and the Pacific Ocean. Indonesia is one of tourist’s favorite destination because of its unique and diverse culture, culinary, views, and people. However, due to its different lifestyle and climate, travelers might get infected by Indonesia’s common traveler disease such as Malaria, Diarrhea, Tuberculosis and others.

According to CDC, Tuberculosis is listed on the second place for top causes of death in Indonesia, with 318.949 cases reported to WHO in 2013. Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis. The person can be infected by inhaling tiny droplets from the coughs or sneezes of an infected person. Tuberculosis occurs worldwide and commonly spreads in overcrowded conditions. Travelers are at greater risk when they are in areas where Tuberculosis is endemic.

The infected person can get symptoms such as chronic cough, weight loss or loss of appetite, night sweats, fever, and fatigue(5). Early diagnosis can be checked through chest xray, blood tests and also Mantoux test(6). There are 2 types of prevention, primary and secondary. Primary prevention is to prevent bacteria entering the body which is by taking BCG vaccines and avoiding exposure to people who is suffering from TB. Secondary prevention is when the bacteria has already entered the body but has not been developed to a disease. This type of prevention is by using drugs called INH. As medical students, we came up with an idea called “DECIDE” to prevent the spread of Tuberculosis. “DECIDE” stands for gooD ventilation of air circulation, health Education, Cover mouth when coughing or sneezing, Immunization, and Dispose used tissuE in sealed plastic bag. As the solution, the infected person could take antibiotics for a minimum of 6 months. Still, the best solution is by preventing bacteria entering the body. So, DECIDE before it’s too late!

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Risks of Consuming Ice Cubes to Travellers to Indonesia Unika Atma Jaya, Jakarta Cecillia A. Wulandari, Emiliana Kartika The development of transportation systems makes people can easily travel from one country to another in such low cost and hassle-free. Every place has its own hazard, but most of us rarely pay attention to the health aspect and deny the possibilities that we might get infected by various diseases which we called as travellers’ disease. In Indonesia the most common travellers’ diseases are hepatitis A and typhoid. Contaminated water and food are the main problems which cause these diseases.

We all know that water is one of human basic needs and most of us put a huge attention about the quality of water we drink every day. But, only a few of us pay attention to the ice cubes served in our beverages, whether it is made of clean water or not. Whereas, adding ice cubes is one good way to have your beverages cool in longer times, especially in tropical countries such as Indonesia. If those ice cubes are made of contaminated water or poor-hygiene tools are used to make ice cubes, then it is possible that the ice cubes contain bacteria that cause some diseases.

In one study published in JAMA in 2004, it is noted that 125 (62%) of food vendors surveyed in Jakarta using ice cubes in the beverages they sell. From 23 samples taken on that study, research showed that all of the ice cubes were contaminated.

The lack of awareness about the importance of consuming clean ice cubes becomes our concern. Thus, through this poster we would like to make people to be aware of consuming contaminated ice cubes. Beside vaccination, we offer solution by consuming cooled beverages instead of adding ice, to prevent the transmission of some travellers’ diseases through contaminated ice cubes. Have you figured out how nice is your ice?

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Beware Typhoid Fever Is Everywhere Maranatha Christian University K Risang, Kadek R A, Devita Wardhani Indonesia is one of the popular destination country toward foreign tourists due to her cultural varieties such as traditional dances, foods, musics, and her nature such as beaches, mounts, and lakes. This developing country has a low sanitary, high population rate and air pollution in several metropolitan cities. Due to these conditions, one of the most common tourism health problems is Typhoid Fever.

Typhoid Fever is caused by Salmonella typhi. It has incubation period of 6 - 30 days with several manifestations like fever in the evening, coated tongue, malaise, constipation or diarrhea. Hygiene of water in Indonesia is very less therefore we can't drink raw water carelessly like drinking water from the tap as has been done by people in developed countries. Tourists usually have a busy schedule to visit many sights, it decrease their concern about body hygiene and immunity.

Tourists must know more about their destination country from the terms of tourism and health to avoid typhoid fever. They also must prepare a good body condition with doing typhoid vaccinates before visit Indonesia.

Besides that, tourist should keep diet and be smart to choose the hygiene and health of food sellers'. They must manage schedule to have time to rest (7-8 hours/day), consume multivitamin to get a good condition, and still keep body hygiene (take a bath and wash their hand before eat).

Prepare your condition carefully and be smart traveler so you can enjoy your traveling.

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Typhoid Fever’s Imperceptible Transmission Putri Maharani, Christopher Adhisasmita Yandoyo Trisakti University Typhoid Fever is a multisystemic infectious disease caused by a Gram-negative organism Salmonella enterica - either serovar Typhi (S. typhi) or serovar Paratyphi (S. paratyphi). The incidence of enteric (typhoid) fever in travelers is estimated to be ∼3–30 cases per 100,000 travelers to developing countries. In Indonesia, a tendency of increasing incidence of typhoid fever increases in past few years. Indonesian Ministry of Health has reported various prevalence of typhoid fever depends on each region and usually related to its environmental sanitation; in Rural area (West Java) 157 cases per 100.000 population, whereas in urban area 760-810 cases per 100.000 population with Case fatality rate (CFR) in the amount of 1,08% among all mortality incidence in Indonesia. Lack of knowledge and hygiene is the most common risk factor of this disease in many developing countries. We can simply promote that healthy environment among travellers travelling across Indonesia by washing our hands before eating, drinking bottled water, and eating clean and cooked food. Even Salmonella enterica is basically food borne disease, it still can live in a water or liquid for about two weeks. By doing those simple things that still many people miss about, surely we can prevent transmission of Salmonella enterica cause nobody barely knew what their hands getting on.

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Kevin Sastra Dhinata Clarissa Cita Magdalena Anthomina Maya Rantesalu Airlangga University Typhoid is one of the most common traveler’s disease in Indonesia. It infects a lot of travelers who travel without taking precautions to Indonesia each year. Data from the Ministry of Health of the Republic of Indonesia shows that, based in a research conducted in 2001, the occurrence of typhoid is 350-810 incidences per 100,000 population, which is a relatively enormous number.The disease itself is mainly caused by the infection of the bacterium Salmonella typhii, which infects people / travelers by entering the human bodies through contaminated water and food consumed by travelers during their trip in Indonesia. Other factors related to poor hygiene and sanitation also contribute to the spread of typhoid to the travelers going to Indonesia, such as contamination of infected people’s feces or waste products, or poor preparation of food and beverages for the travelers during their trip. The symptoms of typhoid may be difficult to find at first, but the most visible symptoms are high fever (39-40 degrees Celcius), stomach pain, loss of appetite, headache, and feeling weak. Even though the spread of typhoid in Indonesia shows a decline due to improved life standards, it still threatens the incoming travelers, and it is not yet fully abolished. But, it doesn’t mean that typhoid is inevitable. We can prevent typhoid by putting a concern of the hygiene of our diet during trip and get a pre-tour vaccination (CDC, 2013).

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Beware of Dengue Raditya Rizki Muhammad Hanum Widiana Nadhya Nur Fitri Universitas Airlangga Since 1968 to 2009, the World Health Organization records Indonesia as the country with the highest case of Dengue Hemorrhagic Fever in South East Asia. The high incidence and case fatality rate of dengue in Indonesia indicates that dengue infection could not be handled yet.

Dengue is caused by the dengue virus, member of the family flaviviridae and transmitted by the bite of Aedes aegypty mosquito, also known as the Asian Tiger Virus. There are four serotypes of dengue virus: DEN-1, DEN-2, DEN-3 and DEN4, all present in Indonesia.

The aedes mosquitoes are well adapted to urban environment. They breed in tires, cans, and water jars near human dwellings, and the females transmit dengue readily because of their predilection for human blood and habit of multiple, interrupted feedings.

The prevention of dengue infection may be conducted by management of the environment, preventing the development of mosquito larva. At an individual level prevention, it is advised that travelers do not visit Indonesia in the wet season in October to March, the favorable breeding time for Aedes mosquitoes.

Travelers should also wear bright colored long sleeved clothing and apply mosquito repellants on exposed parts of their skin. It is also important to understand the course of the disease and symptoms of dengue infection so travelers could seek immediate medical support in case the traveler is infected.

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Know It To Prevent It Andre Indrawan, Margaretha Nathania, Kezia Eveline Airlangga University Dengue is endemic in most tropical and subtropical countries, which are popular tourist destination. Dengue fever has been reported as the second most frequent cause of hospitalization (after malaria) among travelers returning from the tropics. Based on KOMPAS, the number of deaths around 1,317 people in 2010, Indonesia ranks highest cases of dengue hemorrhagic fever in ASEAN. Dengue is a self-limited, systemic viral infection transmitted between humans by mosquitoes (Aedes aegypti). The incubation period ranges from 4 to 7 days. After the incubation period, there are some few signs of dengue, such as fever, severe headache, and aching joints and muscles. However, symptoms and signs are not specific. Only labolatory-based diagnosis can show the specific sign of dengue.

People who have dengue fever should rest, drink plenty of fluids and reduce the fever using paracetamol and see a doctor.

There is no vaccine or any specific medicine to treat dengue.

The most effective preventive measures for the single travelers in areas where dengue fever is endemic are avoid mosquito bites by using insect repellent ointment, protective clothing (which is most effective is permethrinimpregnated) and insecticide.

Travelers often forget about their health when they are on trip. And unwittingly there’s something that threaten our lives by infecting our blood. Our objective in this poster is emphasizing how important to protect ourselves by knowing what are attacking us. For pretravel who want to visit endemic areas, it is important to know information about dengue fever, dengue fever risk, signs and symptoms of dengue infection, prevention, and treatment of dengue.

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Traveler’s Diarrhea Akbar Fitrahadi – Yeni Purnamasari AMSA Brawijaya

Estimated 10 million – 2050% of international travelers – affected by this diarrhea annually.

In Indonesia where the paradise of foods and also bacteria, travelers would be more susceptible occurring this disease. Third world problem as hygiene, sanitation, and cleanliness are the first causal agents to this disease. Travelling could be painstakingly uncomfortable when traveler had this disease.

Its unknown source of disease makes blame on infectious agents such as enteropathogen bacteria. Escherichia coli that called ETEC have an enterotoxigenic ability to get the disease occurred accounted for 20-75% of incidence.

These bacteria had known to be living on fecal contaminated foods and water. A great decision to deal with traveler’s diarrhea is including choosing foods and beverages cleverly and carefully. Thus, travelling would become more enjoyable and peace in mind from getting an illness. Choosing a clean and nice place to eat are preferable as a precaution to keep away from infected by ETEC. Meanwhile, as a safety precaution in the third world countries, such as Indonesia, we should know that a hygiene, sanitation, and cleanliness are the big problem. To prevent from getting infected, “Eat Wise, Drink Properly, Keep Hygiene” can be a simple method to remind you what you should do. Eat Wise means you should choose which foods are good to eat. Avoid raw fruits, vegetables, and meat as it can be a source of infecting agents. Drink properly means you must keep in mind to choose good water for activities. Avoiding ice and uncooked water could be a safest choice, even for tooth brushing. Keep Hygiene means you should always do a hygiene standard. A very useful way to keep hygiene is to clean and wash your hands properly. Thus, Traveler’s Diarrhea could be prevented.

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Protect Yourself from Japanese Encephalitis Lala Sri Fadila, Dessy Christine, Rininta Puspitasari, Priscillia Imelda Gadjah Mada University People travelling to Indonesia sometimes can be affected by epidemic diseases related to their trip because of weather, hygiene, insects, and other. There are various common travel diseases in Indonesia. One of them is Japanese Encephalitis.

Japanese encephalitis (JE) is a leading cause of viral encephalitis in Asia with 30,000-50,000 clinical cases reported annually. These disease found in Asia, start from Japan, Philippines, Korea, China, Thailand, Malaysia until to Indonesia and India.

JE is a viral disease that infects animals and human. The virus often found in pigs and birds, as usual hosts, and transmitted to human by mosquitos.

Thus, mosquitos have an important role here. The incidence of JE increases if mosquito population increases too.

Approximately 1 in 200 infections results in severe disease characterized by rapid onset of high fever, headache, neck stiffness, disorientation, coma, seizures, spastic paralysis and death. Case-fatality rates range from 0.3% to 60% and depends on the population and on age.

In Indonesia, JE virus was firstly isolated in 1972 at Bekasi.

Indonesia was the source for eight of 47 travel-associated cases reported during 1973 to 2011. The area of risk consists of Bali, Irian Barat, Java, Kalimantan, Lombok, Moluccas, Nusa Tenggara, Sulawesi and Irian Jaya.

There is no currently specific treatment. The only way to overcome JE is doing prevention. Through our poster we want to inform people, especially travelers, about how to protect themselves from JE. This disease can be prevented with vaccination. JE vaccine is recommended for native and expatriate residents of endemic areas, and for travellers spending 30 days or more in endemic areas. The other way is to avoid mosquito bites with wearing long-sleeve cloth, using mosquito repellent and also avoid high risk area and travelling during rainy season.

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Typhoid Fever Prevention for Travellers by Vaccination Shofura Afifah Padjadjaran University Typhoid fever is one of the most common diseases that travellers across Indonesia can attract. As Indonesia is a tropical country, and typhoid fever is a disease commonly found in the tropics, it is very easy to spread. Transmitted by a type of salmonella bacteria, this disease is a serious infection common in areas of poor sanitation. As the public health controlls are ineffective, the overall incidence of food- and waterborne disease is very high. Clean water (even drinking water), modern sanitation, and safe food processing and storage is rare in many areas in Indonesia, especially remote areas, and including many travelling destinations.

Travellers need to be responsible for themselves: only drink water that has been confirmed safe to drink, never drink tap water, avoid ice, salads, uncooked seafood, and traditional food and snacks that might have been prepared unhygienically. There is a very wide variety of possible contaminants in every travelling destination in Indonesia, especially for foreigners who may not be intimately acquaintanced with the public health condition in Indonesia.

The typhoid fever vaccine is usually given in a series of two subcutaneous injections given at four weekly intervals. The protection rate is effectively 70%. Booster doses are recommended every 3 years in typhoid-endemic areas. It should not be given to pregnant women and is contraindicated in those convalescent from serious illness.

Hepatitis A shouldn’t be your Keepsake from Indonesia Amani Sakinah Augiani Azkia Al Jundiah Padjadjaran University Hepatitis A is a disease that causes by virus and occurs worldwide, it causes 1-2 million death every year. It is common in developing countries and is generally associated with lack of safe water, poor sanitation and poor hygiene. In 2010, prevalence of Hepatitis A in Indonesia is 9.3% of 237.6 million citizens.

The hepatitis A virus is transmitted primarily by the faecal-oral route. This is when an uninfected person ingests food or water that has been contaminated with the faeces of an infected person. The virus can also be transmitted through close physical contact with an infectious person. The incubation period of hepatitis A is usually 14–28 days.

Prevention of hepatitis A can be done by improve sanitation, food safety, keep adequate supplies of safe drinking water, maintain proper disposal of sewage and personal hygiene.

Immunization is one of the most effective way to prevent it. Most of people develop protective levels of antibodies within one month after a single dose of the vaccine. Millions of people have been immunized worldwide with no serious adverse events. The vaccine can be given as part of regular childhood immunizations programmes and also with other vaccines for travelers. .

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Buzz Away Dengue and Malaria Nadia Gita Ghassani, Sarah Nurul Ramadanti Padjajaran University

Indonesia is well-known as the largest archipelago in the world comprising 17,504 large and small tropical islands. Many traveler come to see beauty of island like Bali, Raja Ampat, Lombok, and so on.

Unfortunately there are serious concern, considering the fact that a total of 608 malarian cases in USA and 12 European countries that were reported over the 6 years acquired after overseas to Indonesia, and more than 50% of all dengue cases in Australia between 1999 and July 2012 were acquired in Indonesia.

Malaria is a serious disease caused by a parasite that commonly infects Anopheles mosquitos whose feeds on humans. It can cause fever and flu-like illness and also anemia and jaundice (yellow coloring of the skin and eyes) because of the loss of red blood cells. Whereas, dengue is caused by virus that transmitted through Aedes Aegypti.

If not promptly treated, the infection can become severe and may cause kidney failure, seizures, coma, and even death.

There are not yet any vaccines to prevent infection with dengue virus. Therefore, prevention for travelers is necessary to be taken is to prevent the bite of mosquitos. It is as simple as to use insect-repellent during the day and night because Anopheles mosquitos commonly attack human at night, while on the other hand Aedes Aegypti mosquitos attack during the day. Wear long sleeves and long pants when having outdoor activity,especially if contact with nature.

Sadly, even the simplest prevention mentioned above are often underestimated by any travelers. We hope that tourist who want to visit Indonesia can be aware of mosquitoborne disease so that they can protect themselves over it. Travelling should ease your mind for its fun, not add your mind with problems like the cost of medications that should be paid for treating malaria or dengue.

Don’t let any be traveler in your body

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Rabies Haunts Rudi Thenggono, Syeba Dinda Hasianna, Almira Zada Neysan Susanto AMSA UNSRI Tourism is one of the main income sources for Indonesia as Indonesia places fourth as the most beautiful countries in the world. Indonesia is gifted with beautiful tropical islands with their very own uniqueness, including Bali. Based on the data from Central Statistics Agency, there is 2.879.600 tourists went to Bali from January until October 2013.

Although Bali is well-known for its beauty, there exist some traveler common diseases which haunt every tourist who come to Bali, and one of them is Rabies. Rabies could be prevented by giving rabies vaccination. The vaccine can be given before the tourists visit Bali. Vaccine boosters are also needed for those who have been given vaccine before.

Tourists are discouraged to approach and feed strayed animal, especially dogs. If they are bitten by infected animals, the saliva will be in contact with wounded area, hence the wound should see a doctor and be treated immediately.

By increasing the awareness and knowledge of Rabies with producing this poster, we hope that the rabies cases happening in Bali could decrease. So, tourists who are travelling to Bali could enjoy their holiday without being afraid of rabies as traveler common disease

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Mind the ABCs Against Malaria Liliani Labitta, Wiseley Hong Tarumanagara University Malaria is a disease spread through mosquito bites. In Indonesia, there are 1.25 to 2.5 million probable malaria cases reported every year. Forty five to fifty percent of these are the cases of Plasmodium falciparum, nearly 350,000 are confirmed malaria cases, and around 500 are confirmed malaria deaths.

World Health Organization (WHO) recommends some actions of malaria prevention to avoid mosquito bites such as sleeping under long-lasting insecticidal nets, and using protective clothing and insect repellents. International travellers may also need to take preventive medication (chemoprophylaxis) before, during, and after returning from their travel, depending on the risk of malaria infection in the area that will be visited.

This poster is made with the aim to increase travellers’ awareness by minding or looking out on malaria infections in Indonesia.

Travellers of Indonesia should at least prepare to avoid mosquito bites, be aware of the signs and symptoms for the sake of early diagnosis, and have chemoprophylaxis appropriate to the circumstances of the visited area.

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Travelers Typhoid Alert for Fellow J.Camoya Gersom , Annisa Ayu A. , Made P. Chania Universitas Brawijaya True tralevers never cease from trying out culinary from various sites and places. Food represents a part of cultural character. It is wise for travelers to be cautious regarding their food intake in order to be always healthy while traveling. There are many dangers await thy fellow travelers. One of them, is typhoid fever.

It is best to prevent typhoid fever before it gets you.

So my team motto is "secure yourself from typhoid, before it gets you!" After reviewing every risk factors and etiologies of typhoid fever. We conclude that travelers shall most be aware of water. Almost any kind of food and beverages go through water before they are consumble. So it is important to keep yourself away from tainted source of water. Always keep yourself clean, always keep your food clean. For example, clean and peel fruit and vegetables before eating them, use/drink water only from clean and untainted source.

It's best to avoid food and beverages from street vendors, but most of all, get yourself vaccinated. Further knowledge and prevention of typhoid fever will develop in the upcoming years. So, travelers, brace yourselves, secure yourself before typhoid gets you!

Check Your BAGS Priscillia Imelda, Aprilia Ayu Sholihati Nafisah, Rahmawati Aisyah Priscillia Imelda Universitas Gadjah Mada According to UNWTO (United Nations World Tourism Organization), during 2013, tourist arrivals has grown by 5%, reaching a record of 1,087 million arrivals. By travelling from one place to another, people are unconsciously exposed to some pathogens. Globally, 20-70% of travellers have health problems and 1 out of 100,000 travellers is dead every year. There are many factors that could affect people's health during their trip, such as ages, health statuses, activities, and durations of the trip.

For all these reasons, they are at risk of getting sick.

Based on CDC (Centers for Disease Control and Prevention), the three most common traveller diseases in Indonesia are malaria (84%), diarrhoea (71%), typhoid (53%), and followed by influenza, cholera, hepatitis A, rabies, yellow fever, and measles. Also, in 2007, WHO reported that the highest morbidity of traveller is caused by infectious agents. Airborne transmission disease, especially SARS and avian influenza also spreads rapidly. In 2005-2012, there are 158 deaths from 191 cases reported.

To face all of those diseases, there are many things that have to be prepared. However, the lack of awareness and preparation becomes a major cause of people's illness during the trip. Therefore, in this poster, we suggest easy ways to get yourself prepared and keep your body healthy during trips. So, before you go, check your BAGS (Bring mask, always washing hand, get vaccines, stock some medicines).

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Typhoid Fever and Its Precautions Carissa Putri, Michael Laban, Anthony Frederick Universitas Kristen Krida Wacana Travellers’ disease is a term used to depict an illness caught when someone travels; usually to a less developed area. It is caused by bacterial, viral, fungal, and parasitic infections. Each place has its own endemic disease. In Indonesia, some of well-known travellers’ diseases are hepatitis A, hepatitis B, typhoid, malaria and yellow fever. Amongst those diseases, typhoid fever is an epitome for their prevalence. A study that is conducted in five countries in Asia states Indonesia as the country with second highest incidents of typhoid after India.

Typhoid fever spreads among human by residing in food and water. The contractor of the disease is bacteria named Salmonella typhi. The bacteria live at human’s bloodstream and gastrointestinal tract. Symptoms of typhoid include lasting high fevers, weakness, stomach pains, headache and loss of appetite. These symptoms share some similar features with other tropical diseases, such as malaria, dengue fever, and yellow fever. In many cases, the best treatment for typhoid fever is to give patients antibiotics.

Nonetheless there is a drawback; resistance to multiple antibiotics is increasing among Salmonella.

The people who do not get medical treatment may continue to have fever for weeks or months, and 1 out of 5 might die from complications. One effort we suggest to reduce the spread of this disease is by educating people about the importance of food and water hygiene. In order to not be infected by typhoid, travellers should take precautions by avoiding unhygienic foods and drinks and get vaccinated.

People should eat foods that have been thoroughly cooked. Last but not least, it is recommendable not to eat foods and beverages from street vendors, due to their unhygienic environment.

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Vaccine Avoid Medicine Muhammad Fathi Banna Al Faruqi, Sania Rifa Zaharadina, Ghina Khairesra Muhammad Fathi Banna Al Faruqi Universitas Gadjah Mada World travellers are at high risk of traveller diseases. It is proved by the data of incidence rate of health problem per month during a stay in developing country.

Based on CDC (Centers for Disease Control and Prevention), 1-10% get enterotoxigenic Escherichia coli diarrhoe, malaria, influenza; 0.1-1% get hepatitis A, dengue infection, animal bite with rabies risk; 0.01-0.1% get Hepatitis B, gonorrhoea, typhoid, HIV infection; 0.001-0.01% thypoid. Indonesia is one of the most popular travel destinations with some common traveller diseases such hepatitis A, hepatitis B, typhoid, rabies, cholera, tetanus, malaria, dengue fever, chickenpox, and diarrhoea.

Travellers’ health problems generally happen because of minimum precaution.

This happens due to their lack of awareness to the health issue and information. So, the travellers know less on how to protect themselves during their trip. Beside, the dirty environment, contaminated food and water are also common causal factors. In Indonesia, one way to prevent most common traveller diseases is getting vaccinated before travelling.

Vaccination is a highly effective method of preventing certain infectious diseases. Vaccines are generally very safe and serious adverse reactions are uncommon. For travellers, vaccination offers the possibility of avoiding a number of infectious diseases that may be encountered abroad.

From this poster, we hope that travellers should get vaccinated for diseases relevant with their destination country. Protecting before travelling is important because when travellers get protected it means that disease will difficult to attack them. Travellers who are free from diseases will enjoy their trip and have a safe trip.

So, vaccine will avoid travellers from diseases that automatically make them do not require medicine because they are healthy.

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Diarrhea: Set Your Destination, Set Your Prevention Ayudhea Tannika, Theresia Indriani Prima Chesar, Elisabeth Pauline Tifany Universitas Kristen Krida Wacana Nowadays, travelling is something common among societies. Most people tend to go to another town. When it comes to travelling, we usually look for typical foods at that town.

However, take note that not all the food prepared in a clean condition and wellcooked. Usually when people are not used to the food, traveler’s diarrhea tends to happen easily. The symptoms include diarrhea, nausea, vomiting, abdominal bloating and cramps. Nonetheless, this problem can be avoided by taking a good measure of hygiene such as washing hands and eating wellcooked food. Apart from that, avoid eating at certain place in which its cleanliness is doubtful.

Avoid Low-Hygiene Food For Prevent Transmission of Hepatitis A Elnissi, Jefryanto, Natalia Universitas Kristen Krida Wacana Traveling is an exciting activity, but the traveler must be careful with the diseases that commonly attacking the traveler. One of them is Hepatitis A. Patients are needed to be treated if only the condition of them are getting worse, avoid alcohol during the acute phase, avoid excessive physical activity and plenty of rest. An active immunization is given with a vaccine made from a inactivated virus with a certain dose. Vaccines can protect up to 20 years, however, the hygiene and sanitation improvements are also the important things that people should aware of.

Hepatitis A also can be prevented with a proper hand washing before eating and avoid drinking water which contained with the virus. Clean water with good distribution is the best prevention of transmission.A

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HEPATITIS A Mardhiyah Nur Dini, Novinda Mutiara Fajar, Rizka Karina Mayang Sari Muhammadiyah Palembang University

Indonesia is a thriving country which still needs a help from another country to be an advanced country, and Palembang is one of the tourism area in Indonesia that offers the cultural tourism. For the natural beauty, Palembang offers the beautiful view of Musi River.

We are as the medical students of Muhammadiyah University want to give the information about the prevention of Hepatitis A for the tourists who want to visit Palembang.

Hepatitis A is a viral infection disease cause by hepatotropic which is systematic and acute. Hepatitis A can occur is many thriving countries, especially in the urban area that have a low level of hygiene and sanitation.

Hepatitis A spreads through the direct contact with drug users and syringes as

suffer Hepatitis

well as from non-hygienic food or contaminated water people who A will have

the symptoms, such as: lack of appetite, fever, dehydration, nausea, pale-colour urine, pale-feces, skin turn yellow.

ways to prevent

eyes and Two this disease:

First, the general prevention of this disease is by eating and drink hygienic food and

doing the sanitation of environment. beverage,

Second, the special prevention of this disease is by doing the passive immunization with inactivated HAV (Hepatitis A Virus) vaccine.

So, keep the environment that you’ll visit clean and do not eat food that is not hygiene to prevent you from Hepatitis A.

People who suffer Hepatitis A can infect other people after infected 1-2 weeks.

Commonly, this disease occurs during 1-3 weeks. Hepatitis A does not lead to the chronic liver.

A death caused by Hepatitis A is rare.

People, who suffer Hepatitis A, can be cared by maintaining health and keeping the environment clean, because this disease can gradually recover if the patient is in a clean environment.

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Warning, MALARIA Spy and Bite You Universitas Muhammadiyah Palembang Traveler disease is a disease who can get when the people traveling to an endemic place. One of the endemic disease in Indonesia is Malaria.

In 2010, WHO reported that were 655.000 people death cause Malaria in the world and 86% these death occur in children under 5 year. In Indonesia on 2010, any 467.764 positif malaria’s cases and on 2012 decreased to 417.819 cases.

Malaria is a infectius disease caused by Plasmodium parasites that live and multiple in red blood cell (erythrocyt). This infectius disease transmitted by the mosquitoes (woman Anopheles). Malaria can affect everyone, man or woman, and all ages.

Any quotes said "prevent is more better than treatment.”. Malaria prevention can be done with used profilaksis (antimalaria drugs) for prevent malaria and when we in endemic malaria area, the prevent can we do with use the long clothes to avoid from mosquitoes, used netting before sleep and used anti-mosquitoes to kill mosquitoe We hope people will have knowledge to know the first symptom of malaria after seeing this poster and if one of their family have a same symptom with malaria’s symptom can give treatment by a doctor. To know the symptom of malaria is very important because can avoid the complication from severe malaria which can make demise and also the treatment will be much easier.

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Wipeout the threats of Dengue Yodha Pranata, Kadek Lina K. D., Ella Ade Y. Universitas Brawijaya

Universitas Pelita Harapan One thing that perhaps many travellers fail to consider is that during their travel to a certain destination is the fact that they may be exposed to diseases common in that destination. There is a lack of awareness that travellers need to prepare themselves to prevent them from contracting the diseases common to their travel destination. Therefore, there is a need to raise awareness among travellers that they need sufficient medical preparation and knowledge about the common traveller disease in their travel destination prior to their travel. In response to that, this public poster is aimed to educate international travellers, who are planning to visit Indonesia, about one of the common traveller diseases in Indonesia, typhoid.

Typhoid is a preventable disease caused by bacteria, Salmonella typhii. This is due to the relatively lower hygiene level of Indonesia’s food vendors as compared to those from the more developed countries where most of the travellers come from. Symptoms of typhoid are constipation, cough, headache, loss of appetite, stomach pains, and sore throat.

Typ hoid can be prevented by vaccination that can be provided by General Practitioners (GP) prior to travel.

Travellers are advised to seek medical advice from General Practitioners prior to travel. Typhoid can be prevented by ensuring good hygiene such as being aware of the hygiene of the foods bought throughout the stay in Indonesia, eating foods that are freshly prepared and cooked, washing hands properly before eating, and refraining from using tap water.

Travellers are advised to seek medical attention in Indonesia should they feel unwell with the symptoms of typhoid.

Dengue is a mosquito-borne viral infection which is transmitted between people by Aedes mosquitoes. This disease become a leading of hospitalization and life-threatening illnes.

Nowdays, the incidence of dengue has grown around the world and become major public health concern. Depending on the travel destination, travellers may be exposed to a number of infectious diseases; exposure depends on the presence of infectious agents in the area to be visited. There is a significant risk for travellers in areas where dengue is endemic and in areas affected by epidemics of dengue.

Epidemic dengue has spread to new areas and has increased in the already affected areas of the region, included Indonesia. There is no specific vaccine for dengue, so the only method to control or prevent the transmission of dengue virus is to fight against vector mosquitoes. This poster suggest to raise awareness among the traveler who came to Indonesia about the dengue’s symptoms and things that should do to prevent affected by dengue. The things that should do to prevent is through “BALINESSE”. It sounds easier to remember by traveller. Dengue should be suspected when a high fever is accompanied by two of the following symptoms: severe headache, muscle and joint pains, nausea, vomiting and swollen glands or rash. Symptoms usually last for 2–7 days, after an incubation period of 4–10 days after the bite from an infected mosquito. With this knowledges about symptoms and how to prevent Dengue, we hope that the traveller can wipeout the threats of Dengue and enjoy Indonesia safely. So, lets spread this information like the bubbles to decrease the incidence of dengue.

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Photograph y

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Street Food Muhammad Hafidl Hasbullah University of Brawijaya

Hand Washing for Hygiene Muhammad Hafidl Hasbullah University of Brawijaya

This picture depicts a boy who was eating snacks on the roadside. In that place looks a lot of vehicles passing nearby. From this picture we can see that the roadside food is not always hygienic.

Besides the air pollution as a result of passing vehicles, the substant and material from the foods are not always safe for consumption.

Roadside foods are often found in public places eespecially in tourism areas.

Besides cheap, the kind of street foods also variative and tasty. But, as a traveler we also should consider the quality of food that we eat when having this culinary travel, such as the hygiene, nutritional content, food processing and way of presentation. These street foods are not always safe for consuming.

Diarhea is a disease that occur a people who eat unhygienic or contaminated foods. Therefore, as a traveler before deciding to eat anything, we should always pay attention to what we eat. The composition, processing method, manner of presentation, or the location where it shold are the consideration criteria. We are what we eat. If we want to have a healthy life and safe travels, we should pay attention to what we eat. Because healthy is a choice.

Hand washing is an action that important to keep the health and sanitation, and escape from many kind of diseases. Some diseases that may occur when we are not washing our hands are diarrhea and infection.

Direct touch to some people, surface of some objects, vehicles, foods, and pets could cause accumulation of germs and microbes in our hand especially on our hand’s palm. The contaminated hand can spread some disease to our body by mouth, eyes, ore nose that touched. It mean the germs and microbes will move to mouth, eyes, and nose and occur some disease.

In addition, without awareness, we also spread our disease to other people that we touch directly or from some object that we touch before.

The routine and discipline of hand washing before and after doing some activities such as before eat, after from toilet, after touch a pet, before and after cook, etc will prevent the spreading of disease and infection. Let us start wash our hand routinely and let us start from ourselves for better health’s quality.

Because health is a choice

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Higher The Mountain, Thinner The Air Abinisa Inaya Taim Universitas Indonesia

That Case Starts From Here Illona Okvita Wiyogo Airlangga University

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Amongst Indonesia active volcano, mount Rinjani is rather popular with 19.782 climbers in 2012.

As the third highest mountain in Indonesia (3726 m) mount Rinjani also known as ‘obyek wisata maut’.

Mountain climbing is one of it.

Unfortunately, it is underestimated.

As we go up a mountain, the air becomes less compressed and is therefore thinner. The thinner air means there is less oxygen to breathe causing hypoxia; which can cause Acute mountain sickness (AMS In summary, the higher number of tourist comes with higher risk of traveler disease. Most of them are preventable. Along with infectious disease, travel accidents including mountain climbing contribute high number of death. In general, comprehensive preparation is needed to insure a happy and healthy traveling.

In that picture, we can see quite large trash located in the crowded and among of food stalls. This thing made the view became not picturesque and the smell of rotting garbage could disturb travelers who want to enjoy the place.

According to National Center for Immunization and Respiratory Diseases: Division of Bacterial Diseases(2006), every year there are 20%-50% travelers who are infected

by Diarrhea. Therefore, we can conclude that the case of Diarrhea in travelerscan be started from tourism spot that isn’t hygiene enough like place in that picture.

Prove of the above is expected to sensitize people to keep clean especially the hygiene of foods and drinks and hoped that people can choose the right place to put the trash.

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Traveler’s diarrhea is a most common illness among travelers because of the meal that they consumed in their trip contained causal pathogen .These pathogen in their food may come from undercooked meal, unhygiene way of serving food, or contaminated environment. To prevent this disease, there are two sides that must be concerned: traveler and foodseller.

This photo was taken in Pasar Putiah, traditional food court in Bukittinggi, West Sumatera. Here is Mrs. Tina, the owner of Katupek Pical Ni Tina, was preparing Katupek Pical.

She has served food like this for 25 years, using only her bare hands to grab the ingredients of Katupek Pical. I asked to Mrs. Tina about her habit of serving food without hand protection and suggesting her to use hand glove to minimize microbial transmission from hands to food while preparing the food in order to prevent disease like diarrhea.

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Foodseller Side of Traveler’s Diarrhea Muhammad Reynald Aditya Universitas Indonesia

This photo was taken at the peak of mount Rinjani, Nusa Tenggara BaratBased on this photo, it is not surprising how mountain climbing could become one of the most anticipated tourism activities. Badan Pusat Statistik (BPS) stated that one of the most interested tourist attractions in 2013 is mountain climbing (>35%).

This increasing number of tourist is not only brought advantage for Indonesian tourism; unfortunately several disadvantages may occur. At first, the symptoms are dizzy, shivering, disoriented, paralysis, pale or cyanotic .If not treated immediately this condition could lead to death.

The prevention mostly concerns on the preparation before mount climbing. Sleep well, exercise, eat properly, drink plenty of water, and bring lots of dry and thick clothes could help prevents hypothermia. Margaret Young once said that climbing is as close as we can come to flying, but if we are not prepared, as it is to dying.

Climbing Is As Close As We Can Come To Flying…Or Dying?

Kindy Aulia Rasyid Universitas Indonesia

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The Feast Ahmad Aulia Rizaly, Fatimah Zahra Anwar, Aulia Afriani M. Hasanuddin University This is the photo of a student exchange participant in Makassar from Japan, Kaiya Shimada, eating in one of the famous eatery place in Makassar. The hygiene and cleanliness in food stalls, restaurants, and eatery in Indonesia are the things he complains the most and oftentimes give him diarrhea. As shown in the photograph, he eats nearby a trashcan and a bathroom that has no door and covered only with curtain-like inside an eatery.

As we all know, diarrhea is the most common disease that infects international tourist, especially in Indonesia. The bad hygiene of the eating place, the cooks, and the way they make foods is an open door for bacteria and virus to infect people so that they can have diarrhea. Moreover, cleanliness and hygiene are not major issues for restaurants owners’ to be concerned which make the situation even worse.

The message that we are trying to spread through our photograph is to open people’s eyes that this is the reality that is happening right now. The reality that may cause harm not only for us, but also for people that come and visit Indonesia. We are trying to raise more awareness to the people to pay more attention in hygiene and cleanliness of eating places, eateries, and restaurants in Indonesia. By paying more attention to those issues, we believe we can prevent diarrhea in the tourists that visit Indonesia which brings more comfort to them and giving a better image of a healthy Indonesia.

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Diarrhea Attact Your Children !

Amelia Mahmudah Universitas Muhammadiyah Palembang

Diarrhea caused by enteric infections is a major factor in morbidity and mortality worldwide. An estimated 2–4 billion episodes of infectious diarrhea occur each year and are especially prevalent in infants. This review highlights the cellular and molecular mechanisms underlying diarrhea associated with the three classes of infectious agents, i.e., bacteria, viruses and parasites. In developing countries, enteric bacterial pathogens and parasites are the leading cause of infectious diarrhea.

Attention should be given to efforts to understand effective promotion Diarrhea Children ! strategies andAttact how Your to sustain behavior Ameliahave Mahmudah change. Studies shown that 70% Universitas Muhammadiyah community participation wasPalembang supported by daily or weekly reminders expensive to provide on a large scale basis. Family sanitation and hygiene education may be more effective than a community piped water system.

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Beware of Aedes Aegypti Bite Chintya Puspaharani Universitas Muhammadiyah Palembang

This photo take in one of Palembangnese’s home. From this photo we can see the situation of this house has a high risk of becoming breeding grounds for mosquitoes Aedes aegypti.

Aedes aegypti breeds mainly in manmade containers such as earthenware jars, metal drums and concrete cisterns used for domestic water storage, but discarded plastic food containers and toys, old tyres and other items that can collect rainwater, gutters , and drains.

There is as yet no vaccine to protect against Dengue fever and the only way to prevent dengue virus transmission is to avoid being bitten by Beware of Aedes Aegypti Bite the disease-carrying mosquitoes.

Chintya Puspaharani

From this photo hopefully we are Universitas Muhammadiyah Palembang able to persuade the society to take reasonable precautions to prevent dengue disease. Let us together prevent the deployment of dengue fever towards a better life.

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Protect Yourself Because Every Moment Was So Precious Rayma Hayati Palangka Raya University

Your Step, Your Safety Ni Kadek Ayu Depy Irmayanti Brawijaya University

Today, Tetanus has been a common disease in every country that causing a mortality. World Health Organization (WHO) said that more than 377.000 death caused by Tetanus.

Tetanus spora spreads in animal’s feces and ground, so it’s easily to contaminate with human skin. Besides that, rusty objects can be the main cause of the infection.

Here we have to be more concern with our holiday because in every step of our journey may damage us like that picture. We can imagine if the rusty objects was trampled by us while walking and we didn’t get the Tetanus vaccine yet, our holiday will be broken only in a short time. So here, I will give some ways to avoid disease while travelling and make your journey fun.

Indonesia is one of the most popular destinations for world traveller with diverse experiences available here.

Preparation before visit indonesia will help protect your health. To assist you in recognising and understanding some of the major travel health risks you may face while travelling. Vaccination is recommended for travellers to areas where environmental sanitation & personal hygiene may be poor. But the vaccines are not completely effective.

Avoiding risky foods will also help protect you from the disease. This will lower the chance that you can get typhoid fever.

Typhoid fever can occur at anytime and anywhere while you have a mild infection. So, you should know about typhoid fever and what steps you can take to protect yourself because every moment of the journey was so precious. Repair and repent.

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BRAINS IMSTC AMSA Indonesia 2014

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