PREFACE

Thanks to Allah SWT for helping and give uschance to finish this Scenario C
tutorial report on the XXII blok timely. Shalawat and salam always be with our
prophet Muhammad SAW and his family, friends, and followers until the end of time.

We recognize that this tutorial report is far from perfect. Therefore we expect
constructive criticism and suggestions, in order to refine the next tasks.

In completing this tutorial task, we got a lot of help, guidance and advice. On
this occasion we would like to express our respect and gratitude to:

1. dr. Anita Masidin, MS, Sp. OK as tutor of group 2

2. All of the members who involved in the making of this report

May Allah SWT give a reward for all the charity given to all those who have
supported us and hopefully this tutorial report, useful for us and the development of
science. May we always be in the protection of Allah SWT. Amen.

Palembang, November 6st, 2018

Author

1
 TABLE OF CONTENT

PREFACE ..................................................................................................................1

TABLE OF CONTENT .............................................................................................2

CHAPTER I INTRODUCTION

1.1 Issue Background ..........................................................................................3

1.2 Purpose and Objectives .................................................................................3

BAB II DISCUSSION

2.1 Tutorial Data .................................................................................................4

2.2 Case Scenario ................................................................................................4

2.3 Clarification of Terms ...................................................................................5

2.4 Identification of Problem ..............................................................................6

2.5 Analysis and Synthesis of Problem ...............................................................7

2.6 Knot...............................................................................................................39

2.7 Conceptual Framework .................................................................................40

Bibliography .......................................................................................................41

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 CHAPTER I
INTRODUCTION

1.1 Issue Background

Community medical science and public healthis the XXII blok in the seven
semester of Competency Based Curriculum of Medical Education Faculty of
Medicine, Muhammadiyah University of Palembang.
In this occasion already implemented tutorial with case C dr. Aris was
appointed as the head of disaster management team in Donggala District, he got
reports from surveillance team that there was an outbreak of a diarrhea and ARI
(Acute Respiratory Infection) on population of evacuated people. Previously
Diarrhea and ARI were th endemic disease and now there was two fold increase
of the incidence.

1.2 Purpose and Objectives

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system at the
Faculty of Medicine, Muhammadiyah University of Palembang.
2. Can solve the case given in the scenario with the method of analysis and
learning group discussion.
3. Achieving the objectives of the tutorial learning method.

3
 CHAPTER II

DISCUSSION

2.1 Tutorial Data

Tutor : dr. Anita Masidin, MS, Sp. OK
Moderator : Yuni Ayu Lestari
Secretary : Mafazi Nataza Putra
Notulis : Okta Isviyanti
Day and date : Tuesday, November 6th, 2018
(13.00 am -14.30 pm)
Thursday, November 8th, 2018
(13.00 am – 14.30 pm)
Rule of tutorial : 1. Gadget should be nonactive or in silent mode.
2. Everyone in the group should express their opinion.
3. ask for permission if want to go outside.
4. Eating and drinking are not allowed in the room.

2.2 Case Scenario

“Disaster at Donggala district”
Dr. Aris was appointed as the head of disaster management team in Donggala
District, he got reports from surveillance team that there was an outbreak of a
diarrhea and ARI (Acute Respiratory Infection) on population of evacuated
people. Previously Diarrhea and ARI were th endemic disease and now there was
two fold increase of the incidence.

As a result of the disaster, the residential environment became severely damaged,

the river which was the source of drinking water for the population was polluted,
and the air was filled with dust due to a collapsed building. The community has
difficulty defecating because the toilet was destroyed by the earthquake.

4
 Dr. Aris plan to investigate the outbreaks in order to prevent transmission and to
the seek the source of disease transmission, He will also provide public education
to prevent transmission of the disease.

2.3 Clarification of Terms

1 Surveillance Collecting analizing data continously and
systematicaly then disseminated to responsible for
diseuse prevention and other health problem
2 Endemic Total case of a certain desease that appeur at
certaintime and certain area in a apopulation
3 Diarrhea The condition of having at least 3 loose of liquid
bowel movement each day

4 ARI Acute respiratory infection is infection that interfered

with the respiratory process for some of people
caised log virus, or bactery that attacks nose, trachea
or lungs

5 Polluted Contaminate (water, air, or a place) with harmful or

poisonous substances.
6 Insidence A measure of the probability of occurrence of a given
medical condition in a population within a specified
period of time.
7 Dust Dry powder consisting of tiny particles of earth or
waste matter lying on the ground or on surfaces or
carried in the air.

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 8 Public education An effort to improve the ability of the community
through self learning by and for the community to get
it help themselves, and develop activities community-
based social and cultural resourceslocal and
supported by public policies health minded
9 Outbreak A sudden occcurance of something unwelcome such
as war or disease

10 Prevent Precautions for the spread of a disease

transmission
11 Source of disease All objects including people or animals that can pass
transmission or cause disease to people

12 Public education Giving a knowledge and ability of person through

learning practice technique or instruction for the
purpose of changing or affecting individual human
behaviour groups and communities for can be more
independent in achieving healthy life goals
13 Report Give a spoken or written account of something that
one has observed, heard, done or investigated.

2.4 Identification of Problem

1. Dr. Aris was appointed as the head of disaster management team in Donggala
District, he got reports from surveillance team that there was an outbreak of a
diarrhea and ARI (Acute Respiratory Infection) on population of evacuated
people. Previously Diarrhea and ARI were th endemic disease and now there
was two fold increase of the incidence.
2. As a result of the disaster, the residential environment became severely
damaged, the river which was the source of drinking water for the population
was polluted, and the air was filled with dust due to a collapsed building. The

6
 community has difficulty defecating because the toilet was destroyed by the
earthquake.
3. Dr. Aris plan to investigate the outbreaks in order to prevent transmission and
to the seek the source of disease transmission, He will also provide public
education to prevent transmission of the disease.

2.5 Analysis of Problem

1. Dr. Aris was appointed as the head of disaster management team in
Donggala District, he got reports from surveillance team that there was
an outbreak of a diarrhea and ARI (Acute Respiratory Infection) on
population of evacuated people. Previously Diarrhea and ARI were th
endemic disease and now there was two fold increase of the incidence.
a. What is the head of disaster management?
Answer:
The head of disaster management is the badan penanggulangan bencana
daerah/Regional Disaster Management Agency (BPBD) is a non-
departmental government agency that carries out disaster management tasks
in both the Province and District / City by referring to the policies set by the
National Disaster Management Agency.

b. What are the task of the head of disaster management?

Answer:
In accordance with Law Number 24 of 2007 Article 4, the Regional
Disaster Management Agency has the duty:
1. Establish guidelines and directives for disaster management efforts that
include disaster prevention, emergency response, rehabilitation, and
reconstruction fairly and equally.
2. Establish standardization and the need for implementing disaster
management based on legislation.
3. Arrange, determine, and inform disaster-prone maps.

7
 4. Report the implementation of disaster management to the Regional
Head every month under normal conditions and at all times in disaster
emergency conditions;
5. Controlling the collection and distribution of money and goods.
6. To account for the use of the budget received from the Budget for
Expenditures Area.
7. Carry out other obligations in accordance with the laws and regulations.

c. What is the difference of incidence, prevalence, rate, ratio, proportion?

(general)
Answer:

INCIDENCE
Incidence is the rate of new (or newly diagnosed) cases of the disease.
It is generally reported as the number of new cases occurring within a
period of time (e.g., per month, per year). It is more meaningful when the
incidence rate is reported as a fraction of the population at risk of
developing the disease (e.g., per 100,000 or per million population).
Obviously, the accuracy of incidence data depends upon the accuracy of
diagnosis and reporting of the disease. In some cases (including ESRD) it
may be more appropriate to report the rate of treatment of new cases since
these are known, whereas the actual incidence of untreated cases is not
(CDC, 2012). Incidence rates can be further categorized according to
different subsets of the population – e.g., by gender, by racial origin, by age
group or by diagnostic category (CDC, 2012).

PREVALEN
Prevalence is the actual number of cases alive, with the disease either
during a period of time (period prevalence) or at a particular date in time
(point prevalence). Period prevalence provides the better measure of the
disease load since it includes all new cases and all deaths between two

8
dates, whereas point prevalence only counts those alive on a particular date
(CDC, 2012). Prevalence is also most meaningfully reported as the number
of cases as a fraction of the total population at risk and can be further
categorized according to different subsets of the population (CDC, 2012).

RATE

In epidemiology, a rate is a measure of the frequency with which an

event occurs in a defined population over a specified period of time.
Because rates put disease frequency in the perspective of the size of the
population, rates are particularly useful for comparing disease frequency in
different locations, at different times, or among different groups of persons
with potentially different sized populations; that is, a rate is a measure of
risk (CDC, 2012). To a non-epidemiologist, rate means how fast something
is happening or going. The speedometer of a car indicates the car’s speed
or rate of travel in miles or kilometers per hour. This rate is always
reported per some unit of time. Some epidemiologists restrict use of the
term rate to similar measures that are expressed per unit of time. For these
epidemiologists, a rate describes how quickly disease occurs in a
population, for example, 70 new cases of breast cancer per 1,000 women
per year. This measure conveys a sense of the speed with which disease
occurs in a population, and seems to imply that this pattern has occurred
and will continue to occur for the foreseeable future (CDC, 2012).

RATIO

Ratio is the relative magnitude of two quantities or a comparison of

any two values. It is calculated by dividing one interval- or ratio-scale
variable by the other. The numerator and denominator need not be related.
Therefore, one could compare apples with oranges or apples with number
of physician visits (CDC, 2012).

PROPORTION

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 A proportion is the comparison of a part to the whole. It is a type of
ratio in which the numerator is included in the denominator. You might use
a proportion to describe what fraction of clinic patients tested positive for
HIV, or what percentage of the population is younger than 25 years of age.
A proportion may be expressed as a decimal, a fraction, or a
percentage (CDC, 2012).

d. What is the meaning and criteria of outbreak?

Answer:
Outbreaks of Infectious Diseases, hereinafter referred to as Outbreaks,
are the occurrence of an outbreak of an infectious disease in a community
where the number of sufferers increases significantly more than the usual
conditions at certain times and regions and can cause havoc (Permenkes,
2010).
An area can be specified in the KLB condition, if it meets one of the
following criteria:
a. The emergence of a certain infectious disease as referred to in Article 4
which previously did not exist or was unknown in an area.
b. Increased incidence of continuous pain for 3 (three) periods in
consecutive hours, days or weeks according to the type of illness.
c. The increase in the incidence of pain was twice or more compared to the
previous period in the period of hours, days or weeks according to the type
of illness.
d. The number of new patients in a period of 1 (one) month shows a double
or more increase compared to the average number per month in the
previous year.
e. The average number of incidents of pain per month for 1 (one) year
shows an increase of twice or more compared to the average number of
incidents of illness per month in the previous year.

10
 f. The case fatality rate (Case Fatality Rate) in 1 (one) period of time shows
an increase of 50% (fifty percent) or more compared to the case death rate
of a disease in the previous period in the same period of time.
g. The proportion of Proportional Rate of new patients in one period shows
an increase of twice or more compared to the previous period in the same
period.
(Permenkes, 2010)

e. What are the base of government policy towards the outbreak?

Answer:

Law of the Republic of Indonesia Number 29 of 2004 concerning

Medical Practices

Law of the Republic of Indonesia Number 29 of 2004 concerning

Medical Practices, considers (a) that health development is aimed at
increasing awareness, willingness and ability to live a healthy life for
everyone in order to realize optimal health as the only general thing in The
1945 Constitution of the Republic of Indonesia; (b) that health as a human
right must be manifested in the forms of health services for the entire
community through the implementation of quality and affordable public
health development (UU RI No. 29 Tahun 2004).

Law of the Republic of Indonesia Number 29 of 2004 concerning

Medical Practices Chapter I, Article 1, in the Law referred to as "Learning
Practices is activities carried out by doctors and dentists on patients in
health" (UU RI No. 29 Tahun 2004).

11
 Law of the Republic of Indonesia Number 4 of 1984 concerning
Outbreaks of Infectious Diseases

Law of the Republic of Indonesia Number 4 of 1984 concerning

Outbreaks of Infectious Diseases Chapter I Pasal 1, in this Act what is
meant by:

a. Outbreaks of infectious diseases, hereinafter referred to as epidemics,

are the occurrence of an outbreak of an infectious disease in a community
where the number of sufferers increases significantly more than the usual
conditions at certain times and regions and can cause havoc.
b. Sources of disease are humans, animals, plants, and objects containing
and / or polluted by germs, and which can cause epidemics.
c. The Head of the Health Unit is the Head of Government Health
Services.
d. The Minister is the Minister responsible for the health sector.

Law of the Republic of Indonesia Number 4 of 1984 concerning

Outbreaks of Infectious Diseases Chapter I Pasal 2, The purpose and
objective of this Act is to protect the population from the catastrophe
caused by the outbreak as early as possible, in order to improve the ability
of people to live healthily.

Law of the Republic of Indonesia Number 4 of 1984 concerning

Outbreaks of Infectious Diseases Chapter III Pasal 3, Minister determines
certain types of diseases that can cause epidemics.

Law of the Republic of Indonesia Number 4 of 1984 concerning

Outbreaks of Infectious Diseases Chapter IV Pasal 4, Outbreak Areas:

(1) The Minister determines certain areas within the territory of Indonesia
that have contracted the outbreak as an outbreak area.

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(2) The Minister revokes the stipulation of the outbreak area as referred to
in paragraph (1).
(3) The procedures for implementing the provisions referred to in
paragraph (1) and paragraph (2) are regulated by Government Regulation.

Law of the Republic of Indonesia Number 4 of 1984 concerning

Outbreaks of Infectious Diseases Chapter V Pasal 5:

(1) Outbreak prevention efforts include:

a. epidemiological investigation;
b. examination, treatment, care and isolation of patients, including
quarantine measures;
c. prevention and immunization;
d. destruction of causes of disease;
e. handling of corpses due to outbreaks;
f. counseling to the community;
g. other countermeasures.
(2) Outbreak prevention efforts as referred to in paragraph (1) shall be
carried out with due regard to environmental preservation.
(3) The implementation of the provisions in paragraph (1) and paragraph
(2) shall be regulated by Government Regulation.

Law of the Republic of Indonesia Number 4 of 1984 concerning

Outbreaks of Infectious Diseases Chapter VI Pasal 6:

(1) Outbreak prevention efforts as referred to in Article 5 paragraph (1)

are carried out by actively involving the community.
(2) The procedures and conditions for the participation of the community
as referred to in paragraph (1) shall be regulated by Government
Regulation.

13
Republic of Indonesia Government Regulation Number 66 of 2014
concerning Environmental Health

Republic of Indonesia Government Regulation Number 66 of 2014

concerning Environmental Health, Chapter I, Pasal 1, in this Government
Regulation what is meant by:

1. Environmental Health is an effort to prevent diseases and / or health

problems from environmental risk factors to realize healthy environmental
qualities from physical, chemical, biological and social aspects.
2. Environmental Health Quality Standards are technical specifications or
values standardized in environmental media that are related or have a direct
impact on public health.
3. Health Requirements are health technical criteria and provisions in
environmental media.
4. Restructuring is an effort to prevent a decrease in the quality of
environmental media and efforts to improve the quality of environmental
media.
5. Security is an effort to protect public health from risk factors or health
problems.
6. Control is an effort to reduce or eliminate risk factors for diseases and
/ or health problems.
7. Settlements are part of a residential environment consisting of more
than one housing unit that has infrastructure, facilities, public utilities, and
has support for other functional activities in urban areas or rural areas.
8. Workplace is a closed or open, movable or fixed space or field where
labor works, or which laborers often enter for the purpose of a business and
where there are sources or sources of danger.

14
 9. Risk Analysis is a method or approach to examine more carefully the
potential health risks relating to the quality of environmental media.
10. Communication, Information and Education, hereinafter abbreviated
as IEC, is a series of activities aimed at behavior change in maintaining and
improving community hygiene and sanitation, with empowerment,
participation, triggering, and other approaches that are tailored to the
culture of the community.
11. The Central Government, hereinafter referred to as the Government, is
the President of the Republic of Indonesia who holds the authority of the
Government of the Republic of Indonesia as referred to in the 1945
Constitution of the Republic of Indonesia.
12. The Minister is the minister who organizes government affairs in the
health sector.

Republic of Indonesia Government Regulation Number 66 of 2014

concerning Environmental Health, Chapter I, Pasal 2, Environmental
Health regulations aim to realize a healthy environment, both physical,
chemical, biological, and social, which enables everyone to achieve the
highest level of health.

f. What is the meaning of the outbreak in case diarrhea and ARI

significanly?
Answer:
The meaning of an increase in case of diarrhea and ARI significantly is
an outbreak. According to Pasal 1 in Permenkes Number 1501 (2010),
Outbreaks is the occurrence or increase of a disease or mortality
significantly within an area in a certain time and the condition that can lead
become an epidemic (Permenkes RI, 2010).

15
g. What the meaning of surveillance?
Answer:
Surveillance is collecting analizing data continously and
systematicaly then disseminated to responsible for diseuse prevention and
other health problem

h. What are the jobs of the surveillance?

Answer:
The task of surveillance is as follows:
1. Prepare a plan for surveillance activities based on Puskesmas program data
and statutory provisions that apply as work guidelines.
2. Carry out surveillance activities including collecting disease data,
epidemiological investigations, handling of outbreaks and coordination
across related programs in accordance with applicable procedures and
statutory provisions
3. Evaluate the results of the overall surveillance activities.
4. Make notes and reports on activities in the field of duty as material
information and accountability to superiors.
5. Carry out other tasks given by superiors
(Permenkes, 2003)

i. What are the task of Puskesmas Surveillance?

Answer:
Based on the Decree of the Minister of Health No. 1479 / Menkes / SK
/ X / 2003 on Guidelines on the Implementation of Epidemiology
Surveillance System for Infectious Diseases and Non Communicable
Diseases, the role of surveillance of puskesmas is:
1. Data Collection and Processing
The Puskesmas surveillance unit collects and processes STP Puskesmas
data from the outpatient registers & inpatient registers at Puskesmas and

16
 Puskesmas Pembantu, excluding data from non-Puskesmas service units
and health cadres. The collection and processing of data is utilized for
analysis materials and recommendations for follow-up as well as data
distribution.
2. Follow-up Analysis and Recommendation
The Puskesmas surveillance unit conducts monthly analysis of potential
outbreak diseases in its area in the form of a table according to the
village / kelurahan and the weekly disease trend graph, then informs the
results to the Puskesmas Head, as the implementation of local area
monitoring (PWS) or early awareness system of potential outbreak
diseases at the Puskesmas. If there is a tendency to increase the number
of potential disease outbreaks, the Head of Puskesmas will conduct an
epidemiological investigation and inform the District Health Office. The
Puskesmas surveillance unit conducts an annual analysis of disease
progression and links it to risk factors, environmental changes, and
program planning and success. Puskesmas utilize the results as an
annual profile material, Puskesmas planning materials, program and
sector related information and District / Municipal Health Office.
3. Feedback
Puskesmas surveillance unit sent monthly report attendance and data
recovery request to Puskesmas Pembantu in its working area.
4. Reports
Every week, Puskesmas send PWS data of potential disease of KLB
PWS KLB (attached form 3). Every month, Puskesmas sends STP
Puskesmas data to District / City Health Office with the type of disease
and its variables as form STP. EFA (attached form 4). In the PWS data
of potential outbreaks and STP data, this Puskesmas does not include
data on non-health service units and health cadres data Each week, non-
Puskesmas Service Units send PWS data of potential outbreaks to
District Health Offices.

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 (KMK RI, 2003)

j. What are the step of surveillance activities?

Answer:
The decree of minister of health of the republic number 1116/
menkes/sk/VIII/2003 concering guidelines for implementing epidemiology
surveillance system. Health epidemiological surveillance activities are
activities that are carried out continuously and systematically with the
working mechanism as follows:
1. Identification of cases and health problems as well as other relevant
information
2. Recording, reporting, and data processing
3. Analysis and interpretation of data
4. Epidemiological studies
5. Dissemination of information to units that need it
6. Make recommendations and follow-up alternatives
7. Feedback
(Menkes RI, 2003).

k. What is the meaning of endemis?

Answer:
Endemic is (of a disease or condition) regularly found among particular
people or in a certain area (Oxford, 2016). Endemic area is
a geographical region where a particular disease is prevalent.
In epidemiology, an infection is said to be endemic (from Greek ἐν en "in,
within" and δῆμος demos "people") in a population when that infection is
constantly maintained at a baseline level in a geographic area without
external inputs (Cobbs, 2012).

18
l. How the natural history of disease and mode of transmision of ARI
and Diarrhea?
Answer:
Diarrhea:
Transmission of infectious germs that cause diarrhea is transmitted
through Face-Oral germs can be transmitted when entered into the mouth
through food, drink or contaminated objects with feces, such as fingers, food
containers or drinking places to be washed with contaminated water. People
who are covered by clean water supply have a lower risk of diarrhea than
people who do not get clean water. Communities can reduce the risk of
diarrhea by using clean water and protecting the water from contamination
from the source to storage at home (Soepardi, 2011).

ARI:
Transmission of infectious agents through airborne is disease
transmission caused by spreading droplet nuclei that remain infectious when
flying in the air in long distances and long periods of time. Transmission
through the air can be further categorized into "obligate" or "preferential"
transmission (Soepardi, 2011).

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2. As a result of the disaster, the residential environment became severely
damaged, the river which was the source of drinking water for the
population was polluted, and the air was filled with dust due to a
collapsed building. The community has difficulty defecating because the
toilet was destroyed by the earthquake.
a. What is the criteria of polluted water?
Answer:
An water can be said to be polluted if it is present or the appearance of
a physical, biological or chemical substance into the atmosphere in an
amount that exceeds the safe limit so that it can affect the health of
humans, animals and plants and disrupt the activities and comfort of living
things.

b. What are good water source criteria?

Answer:
There are 3 requirements for good water, they are:
1. Physical requirement
The physical requirements for good water are no color, no taste,
and the temperature are must be lower than the temperature of the
environtment around the water.
2. Bacteriological requirement
The water must be free from any kind of bacteri especially the
pathogen one. It can be checked from the sample of the water. If it
contains less than 4 E. Coli bacteri per 100 cc of water, then the
water is safe to consume.
3. Chemical requirements
The water are acceptable if it contains certain substances but in a
certain amount too.

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 Substance Acceptable level
Flour (F) 1-1,5
Chlor (C) 250
Arsenic (Ar) 0,05
Cuprum (Cu) 1,0
Iron (Fe) 0,3
Organic substance 10
Acidity 6,5-9,0
Carbon dioxide 0
(Notoatmodjo, 2011)

Criteria of a good drinking water:

Based on Peraturan Menteri Kesehatan RI No. 492/Menkes/Per/ IV/ 2010
about Persyaratan Kualitas Air Minum Pasal 3 Ayat 1, drinking water is
safe for health when it comply requirements the physical,
microbiological, chemical and radioactive contained in mandatory
parameters and additional parameters.

c. What the health impact when water river was polluted?

Answer:
Some air-related diseases (Waterborne Deseases) have been known for
a long time. Pollution of drinking water by waste water and / or by human
waste (feces), which contains souls that can cause disease, viruses,
pathogenic bacteria and so on, can spread rapidly throughout the system,
and can affect outbreaks or blast the number of people with disease in the
area in a short time. Some of the most frequent diseases include:
dysentery, diarrhea, typhoid, hepatitis A, and cholera (Herlambang, 2006).

21
d. What diseases can be transmitted through water?
Answer:
According to (Workie, Amare, Melake Demena et al. 2003) which
includes wateborne disease are:

Categories Diseases Causes Transmission route of

of agents Caused disease
organisms
Bacterial Shigellosis Shigella. Sp Man-Feces-water-food
and drink-human

Thyphoid Salmonella Man-Feces-water-food

thypi dan and drink-human
salmonella
parathypi
Cholera Vibrio Man-Feces-water-food
Cholera and drink-human
Acute E. coli Man-feces-water-human
Gastroente
ritis
Viral Infectious Hepatitis A Man-feces-water- food
hepatitis virus and drink-human
Hepatitis E
Virus
Poliomyeli Polio virus Man-feces-water-human
tis
Acute Rota Virus Man-feces-water-human
Gastroentr
itis

22
 Protozoal Amebiasis Entamoeba Man-feces-water- food
Hystolitica and drink-human

Giardiasis Giardia Man-feces-water- food

lamblia and drink-human

Helminths Dracuncul Drancunculus Man-water-human

iasis medinesis
(Guinea
Worm)

e. What is the chain of transmission disease?

Answer:
The chain of disease transmission is a way of gathering the
information needed to interrupt or prevent an epidemic. Each of the links in
the chain must be favorable to the organism for the epidemic to continue.
Breaking any link in the chain can disrupt the epidemic. Which link it is
most effective to target will depend on the organism (CDC, 2012).

f. What is the criteria of polluted air?

Answer:
Criteria air Pollutants (CAP), or criteria pollutants, are a set of air
pollutants that cause smog, acid rain, and other health hazards.
CAPs are typically emitted from many sources
in industry, mining, transportation, electricity generation and agriculture.
In many cases they are the products of the combustion of fossil fuels or
industrial processes. There are six criteria air pollutant :
1. Ozone (O3): Ozone found on the surface-level, also known as
tropospheric ozone is also regulated by the NAAQS under the Clean

23
 Air Act. Ozone was originally found to be damaging to grapes in the
1950s. The US EPA set "oxidants" standards in 1971, which included
ozone. These standards were created to reduce agricultural impacts
and other related damages. Like lead, ozone requires a reexamination
of new findings of health and vegetation effects periodically. This
aspect necessitated the creation of a US EPA criteria document.
Further analysis done in 1979 and 1997 made it necessary to
significantly modify the pollution standards
2. Atmospheric particulate matter
 PM10, coarse particles: 2.5 micrometers (μm) to 10 μm in size
(although current implementation includes all particles 10 μm
or less in the standard)
 PM2.5, fine particles: 2.5 μm in size or less. Particulate Matter
(PM) was listed in the 1996 Criteria document issued by the
EPA. In April 2001, the EPA created a Second External
Review Draft of the Air Quality Criteria for PM, which
addressed updated studies done on particulate matter and the
modified pollutant standards done since the First External
Review Draft. In May 2002, a Third External Review Draft
was made, and the EPA revised PM requirements again. After
issuing a fourth version of the document, the EPA issued the
final version in October 2004.
3. Lead (Pb): In the mid-1970s, lead was listed as a criteria air pollutant
that required NAAQS regulation. In 1977, the EPA published a
document which detailed the Air Quality Criteria for lead. This
document was based on the scientific assessments of lead at the time.
Based on this report (1977 Lead AQCD), the EPA established a "1.5
µg/m3 (maximum quarterly calendar average) Pb NAAQS in 1978.[8]"
The Clean Air Act requires periodic review of NAAQS, and new
scientific data published after 1977 made it necessary to revise the

24
 standards previously established in the 1977 Lead AQCD document.
An Addendum to the document was published in 1986 and then again
as a Supplement to the 1986 AQCD/Addendum in 1990. In 1990, a
Lead Staff Paper was prepared by the EPA's Office of Air Quality
Planning and Standards (OPQPS), which was based on information
presented in the 1986 Lead/AQCD/Addendum and 1990 Supplement,
in addition to other OAQPS sponsored lead exposure/risk analyses. In
this paper, it was proposed that the Pb NAAQS be revised further and
presented options for revision to the EPA. The EPA elected to not
modify the Pb NAAQS further, but decided to instead focus on the
1991 U.S. EPA Strategy for Reducing Lead Exposure. The EPA
concentrated on regulatory and remedial clean-up efforts to minimize
Pb exposure from numerous non-air sources that caused more severe
public health risks, and undertook actions to reduce air emissions.
4. Carbon monoxide (CO): The EPA set the first NAAQS for carbon
monoxide in 1971. The primary standard was set at 9 ppm averaged
over an 8-hour period and 35 ppm over a 1-hour period. The majority
of CO emitted into the ambient air is from mobile sources. The EPA
has reviewed and assessed the current scientific literature with respect
to CO in 1979, 1984, 1991, and 1994. After the review in 1984 the
EPA decided to remove the secondary standard for CO due to lack of
significant evidence of the adverse environmental impacts. On January
28, 2011 the EPA decided that the current NAAQS for CO were
sufficient and proposed to keep the existing standards as they stood.
The EPA is strengthening monitoring requirements for CO by calling
for CO monitors to be placed in strategic locations near large urban
areas. Specifically, the EPA has called for monitors to be placed and
operational in CBSA's (core based statistical areas) with populations
over 2.5 million by January 1, 2015; and in CBSA's with populations
of 1 million or more by January 1, 2017. In addition they are requiring

25
 the collocation of CO monitors with NO2 monitors in urban areas
having a population of 1 million for more. As of May 2011 there were
approximately 328 operational CO monitors in place nationwide. The
EPA has provided some authority to the EPA Regional Administrators
to oversee case-by-case requested exceptions and in determining the
need for additional monitoring systems above the minimum
required. The EPA reports the national average concentration of CO
has decreased by 82% since 1980. The last nonattainment designation
was deemed in attainment on September 27, 2010. Currently all areas
in the US are in attainment.
5. Sulfur oxides (SOx): SOx refers to the oxides of sulfur, a highly
reactive group of gases. SO2 is of greatest interest and is used as the
indicator for the entire SOx family. The EPA first set primary and
secondary standards in 1971. Dual primary standards were set at 140
ppb averaged over a 24-hour period, and at 30 ppb averaged annually.
The secondary standard was set at 500 ppb averaged over a 3-hour
period, not to be exceeded more than once a year. The most recent
review took place in 1996 during which the EPA considered
implementing a new NAAQS for 5-minute peaks of SO2 affecting
sensitive populations such as asthmatics. The Agency did not establish
this new NAAQS and kept the existing standards. In 2010 the EPA
decided to replace the dual primary standards with a new 1-hour
standard set at 75 ppb. On March 20, 2012 the EPA "took final action"
to maintain the existing NAAQS as they stood. Only three monitoring
sites have exceeded the current NAAQS for SO2, all of which are
located in the Hawaii Volcanoes National Park. The violations
occurred between 2007-2008 and the state of Hawaii suggested these
should be exempt from regulatory actions due to an 'exceptional event'
(volcanic activity). Since 1980 the national concentration of SO2 in the
ambient air has decreased by 83%. Annual average concentrations

26
 hover between 1-6 ppb. Currently all ACQR's are in attainment for
SO2.
6. Nitrogen oxides (NOx): The EPA first set primary and secondary
standards for the oxides of nitrogen in 1971. Among these are nitric
oxide (NO), nitrous oxide (N2O), and nitrogen dioxide (NO2), all of
which are covered in the NAAQS. NO2 is the oxide measured and
used as the indicator for the entire NOx family as it is of the most
concern due to its quick formation and contribution to the formation of
harmful ground level ozone. In 1971 the primary and secondary
NAAQS for NO2 were both set at an annual average of 0.053 ppm.
The EPA reviewed this NAAQS in 1985 and 1996, and in both cases
concluded that the existing standard was sufficient. The most recent
review by the EPA occurred in 2010, resulting in a new 1-hour
NO2 primary standard set at 100 ppb; the annual average of 0.053 ppm
remained the same. Also considered was a new 1-hour secondary
standard of 100 ppb. This was the first time the EPA reviewed the
environmental impacts separate from the health impacts for this group
of criteria air pollutants Also, in 2010, the EPA decided to ensure
compliance by strengthening monitoring requirements, calling for
increased numbers of monitoring systems near large urban areas and
major roadways. On March 20, 2012 the EPA "took final action" to
maintain the existing NAAQS as they stand. The national average of
NOx concentrations has dropped by 52% since 1980. The annual
concentration for NO2 is reported to be averaging around 10-20 ppb,
and is expected to decrease further with new mobile source
regulations. Currently all areas of the US are classified as in
attainment.

27
g. What the health impact of polluted air?
Answer:
Air pollution has a lot of influence on people's good lives
adults and children. Over the past few years there has been a good disease
in the number of attacked and the type of disease that continues to attack
increase. Asthma is suspected to be a disease that increases in number
sufferers, but other diseases such as allergies, bronchitis and channel
diseases upper respiratory (ARI) also increases sharply. The cause of the
increase in the disease is highly suspected by the occurrence of
environmental pollution (Sumampouw, 2015).

h. How to natural history of disease caused by smoke pollution?

Answer:
Air pollution causes subclinical changes or damage without
symptoms and does not require medication. These subclinical changes
result in reduced pulmonary response and damage at the cellular level.
This damage occurs in everyone who breathes intense air pollution. This is
often not realized because there are no symptoms, but actually air
pollution has damaged. The impact is certainly not now, but 10 or 20
years later, in the later stages, cell damage is more widespread and can
attack the upper respiratory tract to the lower respiratory tract. The
damage begins to show symptoms and requires treatment. In severe
damage, air pollution can cause premature death. several diseases arising
from air pollution such as respiratory infections, asthma, chronic
obstructive pulmonary disease (COPD), and lung cancer.

The transmission of diarrhea is by fecal oral it can be by hands, water and

food. And transmission of Acute Respiratory Infectoin there are :

28
i. What are the criteria of good air?
Answer:
The composition of the air: 78.1 nitrogen, 20.93% oxygen, 0.03%
carbon dioxide, argon gas, neon, krypton, xenon, helium, and can also be
found to contain air, dust, bacteria, spores and plant residues.

29
j. How to measure the quality of air?
Answer:
Air Quality Index
To declare air quality conditions somewhere to do with the air quality
index. Index of air quality designed to provide ease of knowing the
condition of the ambient air quality to the public with simple information,
without having to use the units that are easy to understand society

To determine the environmental quality index, it needs two basic

stages, namely (KEP- 107/Kabapedal/11/1997) :

1. The calculation of the variable sub-indices for each pollutant under

review
2. The merger between sub-indices into a composite index

Some examples of how to declare air quality conditions using several

types of indexes (KEP- 107/ Kabapedal/11/1997) :
1. Index Green
Introduced by Green in 1966. This index covers only two variables
pollutants are SO 2 and coefficients Haze.
2. National Air Quality Index ( National Air Quality Index, Naqi)
Naqi a combination of sub indices five parameters (CO, SO 2
particulates, oxidant and NO 2). The standards are based on standard
quality standard secondary that quality standards are not much related
to the health aspects rnanusia, but many related to material damage,
the impact on plants and animals, decreased vision, decreased levels of
economic and others (KEP- 107/ Kabapedal /11/1997).
Air Pollution Index (ISPU)
Pollution Standard Index (PSI)
The index for the first time introduced by the EPA working groups,
in April 1976 by Thorn et al. Six categories of PSI is a good, safe,

30
 potentially lowering the level of health, unhealthy, unhealthy and
dangerous to health. In all versions, the index value associated with the
PSI = 100 NAAQS and PSI = 500 is a real danger threshold level. A
value of 200, 300 and 400 respectively are alert, warning and
emergency (KEP- 107/ Kabapedal/11/1997).
In Indonesia the concept of the index is used as a reference and
has now been enacted air pollution index (ISPU) by the Minister of
Environment No. KEP-45 / MENLH / 10/1997.
ISPU is not dimensionless number that describes the condition of
the ambient air quality in a given location. Determination of criteria
ISPU based on their impact on human health, aesthetic value and other
living creatures (KEP- 107/ Kabapedal/11/1997).
ISPU value is set by altering the levels of air pollutants measured,
being a dimensionless number. Parameter ISPU is particulate diameter
of less than 10 • m (PM10); Carbon monoxide (CO); sulfur dioxide
(SO 2); nitrogen dioxide (NO 2) and ozone (O 3) (KEP- 107/
Kabapedal/11/1997).
Table 1. Parameter Measurement Period Average ISPU:

Parameter Time

Particulates, PM10 24

Sulfur dioxide, SO 2 24

Carbon monoxide, CO 8

Ozone, O 3 1

Nitrogen dioxide, NO 2 1

31
Table 2. Figures and Categories Air Pollutant Index

Category Range Explanation

Well 0-50 The level of air quality that do not give

effect to human or animal health and no
effect on plants, buildings and aesthetic
value

Moderate 51-100 The air quality level that has no effect on

human or animal health but the effect on
sensitive plant and aesthetic value

Not healthy 101-199 The air quality level that is harmful to

humans or animals sensitive groups or can
cause damage to plants and aesthetic value

Very not 200-299 Levels of air quality that can be

Healthy detrimental to health in a

number of segments of the population

exposed

Dangerous >300 The level of hazardous air quality in

general can harm

serious health in the population

32
k. What type of latrine?
Answer:
1. Cemplung toilet, latrine (pit latrine)
Inside the pit latrine ranged between 1.53 meters. In accordance with
the rural areas, the latrine can be made from bamboo, bamboo walls,
and the roof of coconut leaves or rice leaves. The distance from
drinking water sources is at least 15 meters away.
2. Ventilated cistern (ventilated improved pit latrine = VIP latrine) This
toilet is almost the same as the cemplung latrine, the difference is
more complete, that is using the pipe vent. For rural areas, these
ventilation pipes can be made with bamboo.
3. Toast pond (fishpond latrine) These latrines are built on fish ponds.
4. Fertilizer toilet (the compost privy)
5. In principle, these latrines are like a cemplung latrine, only more
shallow excavations. In addition, the latrine is also to dispose of
animal waste and waste, and leaves.
6. Septic tank
This type of septic tank latrine is the most eligible way, therefore, the
recommended disposal of these stools. Septic tanks consist of a
watertight sedimentary tank, in which faeces and waste water enter
and decompose. In this tank, the stool will be for several days. During
this time, the stool will have 2 processes:

a) Chemical process
b) Biological processes
(Notoadmodjo, 2011)

33
 l. What are good latrine criteria?
Answer:
According Notoadmojo (2011) A toilet called healthy for rural areas
must meet the following requirements:
1. Does not pollute the surface of the soil around the latrine
2. Do not contaminate surface water around it
3. Not pollute the surrounding groundwater
4. Unaffordable by insects especially flies and cockroaches and other
animals
5. Does not cause odor
6. Easy to use and maintain (maintenance)
7. Simple design
8. Cheap
9. Can be accepted by the wearer.

m. What are the health impact when the good latrine system were not
implemented?
Answer:
The impact of good latrine system not implemented is occurrence of
various environtmental-based infectious disease on waterborne disease.
Some diasease that can be caused included hepatitis A, typhoid, diarrhea,
dysentery, cholera, various worms (roundworms, kremi, mines and
ribbons), schistosomiasis and so on.

3. Dr. Aris plan to investigate the outbreaks in order to prevent

transmission and to the seek the source of disease transmission, He will
also provide public education to prevent transmission of the disease.

34
a. What is a personal protective device?
Answer:
Personal protective equipment in the industrial world known as
Personal Protective Equipment (PPE) is equipment used by employees to
protect themselves against potential hazards of workplace accidents. PPE is
a completeness that must be used when working in accordance with the
danger and risk of work to maintain the safety of the workers themselves
and those around them (Lisa,2010).

b. How to step inquiry to investigate outbreaks?

Answer:
According to Regulation of the Minister of Health of the Republic of
Indonesia No 949 / MENKES / SK / VIII / 2004, Investigation of alleged
outbreaks by:

1. In the Health Service Unit, the health worker asks every visitor of the
Health Service Unit about the possibility of an increase in the number of
people suspected of the outbreak at a particular location.

2. In the Health Services Unit, the health worker checks the inpatient and
outpatient registers of any possible increase in suspected cases at a
particular location based on the patient's address, age, and gender or
other characteristics.

3. The health worker interviewed the village head, the head of the
dormitory and everyone who knows the state of the community about
the increase of the suspected disease of the outbreak.

4. Opening of service post at the location of suspected outbreak and

analyzing patient data of treatment to know the possibility of existence
of increase of suspected disease.

35
 5. Visiting suspected persons home or home-to-house visits to all residents
depending on the choice of investigation team (Permenkes RI, 2004).

c. What the goal the investigate outbreaks?

Answer:
 To control the outbreak
 To prevent future outbreaks
 To provide statutorily mandated services
 To strengthen surveillance at local level
 To advance knowledge about a disease
 To provide training opportunities
(WHO, 2009)

The goals of outbreak investigations are:

 To assess the range and extent of the outbreak

 To reduce the number of cases associated with the outbreak
 To prevent future occurrences by identifying and eliminating the
source ofthe problem
 To identify new disease syndromes
 To identify new causes of known disease syndromes
 To assess the efficacy of currently employed prevention strategies
 To address liability concerns
 To train epidemiologists
 To provide for good public relations and educate the public
(Gerstman,B., 2003)

36
d. What is the next step after we got a result from the investigation?
Answer:
Provide public education to prevent transmission of the disease.

e. How to break the chain of disease transmission in this case?

Answer:
The course of the disease begins with exposure to susceptible
individuals by causal agents. Exposure (exposure) is contact or proximity
to the source of the disease agent. In this phase primary prevention can be
carried out by intervening, namely modification of determinants or risk
factors or causes of disease, health promotion, and specific protection
(immunization). . If there is an appropriate attachment and cell entry,
exposure to infectious agents can cause invasion of infectious agents and
infection. The infectious agent performs multiplication that encourages the
process of pathological changes, without the host realizing it. The time
needed starts from exposure to causal agents until the onset of clinical
manifestations called the incubation period (infectious disease) or latency
period (chronic disease). In this phase the disease has not revealed clinical
signs and symptoms, called subclinical disease (asymptomatic). In this
phase to break the chain of disease travel is done by secondary prevention.
Secondary prevention is an effort to prevent the asymptomatic disease
phase, precisely at the preclinical stage, to the emergence of clinical
symptoms through early detection. If detection is not done early and
therapy is not given immediately then adverse clinical symptoms will
occur. Early detection of disease is often called "screening". Screening is
the identification of an unknown disease or disability by applying a test,
examination, or other procedure, which can be done quickly. Screening
tests sort out people who seem to be experiencing illness from people who
don't seem to have the disease. Screening tests are not intended as a
diagnostic. People who are found to be positive or suspicious are referred

37
 to the doctor for the diagnosis and administration of the necessary
treatment (Last, 2001). Subsequently initiation of clinical disease. At this
time clinical signs and symptoms (symptoms) arise from the disease
clinically, and hosts who experience clinical manifestations are called
clinical cases. The earliest clinical symptoms are called prodromal
symptoms. During the clinical stage, clinical manifestations will be
expressed until the final outcome / resolution of the disease, good recovery,
remission, changes in severity, complications, recurrence, relapse,
sequelae, residual dysfunction, disability, or death. The time period for
expressing clinical disease until the end result of the disease is called the
duration of the disease. Covariates that affect progress towards the outcome
of the disease are called prognostic factors (Kleinbaum et al., 1982;
Rothman, 2002). In this phase the action taken is tertiary prevention.
Tertiary prevention is an effort to prevent the progression of the disease
towards various consequences of worse diseases, with the aim of
improving the quality of life of patients. Tertiary prevention is usually
carried out by doctors and a number of other health professions (for
example, physiotherapists).

f. How to do health education to the community?

Answer:
How to conduct health education to community or community that is:
1. public speaking (public speaking)
2. speeches and discussions about health.
3. simulation, for example dialogue between patient and doctor.
4. sinetron.
5. writings in magazines or newspapers.
6. billboards, mounted on the sidewalk, banners, posters, and so on.
(Notoadmodjo, 2011)

38
 4. What is Islamic point on environmental health?
Answer:
Quran Surah Yunus : 101

ِ ‫ت َو ْاْل َ ْر‬
َ‫ض ۚ َو َما ت ُ ْغنِي ْاْليَاتُ َوالنُّذُ ُر ع َْن قَ ْو ٍم ََل يُ ْؤ ِمنُون‬ ِ ‫اوا‬ َّ ‫ظ ُروا َماذَا فِي ال‬
َ ‫س َم‬ ُ ‫قُ ِل ا ْن‬

Say, “Observe what is in the heavens and earth.

Quran Surah Al-Hasyr : 18

َ‫ير ِب َما ت َ ْع َملُون‬

ٌ ‫َّللاَ َخ ِب‬ َّ ‫س َما قَ َّد َمتْ ِلغَ ٍد ۖ َواتَّقُوا‬
َّ َّ‫َّللاَ ۚ ِإن‬ ٌ ‫ظ ْر نَ ْف‬ َّ ‫َيا أَيُّ َها الَّ ِذينَ آ َمنُوا اتَّقُوا‬
ُ ‫َّللاَ َو ْلت َ ْن‬

“O you who have believed, fear Allah . And let every soul look to what it has put
forth for tomorrow - and fear Allah . Indeed, Allah is Acquainted with what you do.”

Quran Surah Al-Hujarat : 6

‫علَ ٰى َما‬ ْ ُ ‫ق ِبنَبَ ٍإ فَتَبَيَّنُوا أ َ ْن ت ُ ِصيبُوا قَ ْو ًما ِب َج َهالَ ٍة فَت‬

َ ‫ص ِب ُحوا‬ ِ ‫يَا أَيُّ َها الَّ ِذينَ آ َمنُوا إِ ْن َجا َء ُك ْم فَا‬
ٌ ‫س‬
َ‫فَعَ ْلت ُ ْم نَاد ِِمين‬

(49:6) “O you who have believed, if there comes to you a disobedient one with
information, investigate, lest you harm a people out of ignorance and become, over
what you have done, regretful.”

2.6 Conclusion
dr. Aris investigating and doing health education to people of donggala because
of the outbreak of diarrhea and ARI (Acute Respiratory infection) due to water
and air pollution.

39
2.7 Conceptual Framework

Natural Disaster

Air Polution Water Polution

Habit of bathing, washing and defecting is not hygienic

ARI Diarrhea

Dr. Aris tries to solve it by investigating and

doing health education

40
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