Day 9: It is My Job!

After an interesting session with Mr. Jamalul Hayat, we moved on to the next and final session by the Unit Kesihatan Pekerjaan Dan Alam Sekitar (KPAS). The officer in charge is PPKP Mr. Adzmir bin Hamzah.

The main duties and role of the unit are
I. Nuisance complaint investigation
II. Health surveillance of employees
III. Inspection of school/ NS camp site
IV. Planning and Coordinating Healthy Settings project.
V. Incident Surveillance among stuff on needle stick injury.

The roles of the KPAS unit can be broadly divided into 2:

A. The health of the workers
• Employment related illnesses and accident notification
• Oversight of medical practice
• JKKKP
• Staff inspection (>35 years old)
• Safety audit
• Training

B. Environmental health
• Haze
• Disaster
• Prosperous place
• Healthy setting

After an overview of the KPAS’s functions, Mr. Adzmir then briefed us on the OSH Act 1994, notification of occupational diseases and poisoning (WEHU D1 & D2), occupational injury (WEHU A1 &A2). The most important part is on the notification of needle stick injury which actually occurred in the year of 2010. He too shares his experience on safety auditing, including at the Illegal Foreign Workers Depot, schools, national service camp site and market. The KPAS unit also responds to complaints from the public regarding environmental health and pollution.

According to Mr. Adzmir, from the year of 2007 to 2010, there is only one healthy setting project being executed per year compared to the year of 2005 and 2006 which is 4 and 2 respectively. This is due to the financial constrains and stagnant development.

Besides this, he shows us some personal protective equipment (PPE) of the DHO staff, mainly foggers. Equipments are mainly purchased from 3M, as recommended by the state level, such as industry helmets, ear plugs, rubber shoes, gloves, and safety goggles. All these are basic equipment to ensure the safety of the employee.

Amazingly, there are no any major occupational injuries or diseases in Sik thus far. The KPAS unit ensures that the authorities provide good safety to the employees by yearly inspection and assessment.


Chan Wai Yee

Day 9: Epidemiology of HIV

Objectives and the need of the programme in District based on statistics (prevalence, incidence or other rates etc.) for the districts.

HIV/AIDS Section of the DHO’s Objectives
1. Reducing the spread of HIV.
2. Reducing the transmission from mother-to-child.
3. Prevention of HIV with NGOs

Issues Identified in the State Plan of Action 2011
1. Poor coverage of Harm Reduction in KKs
2. Need to increase coverage of the Methadone Substitution Clinic to the KKs under the DHO
3. Increased HIV infections through sexual contact

Issues in Sik
1. Ignorance
2. Lack of activities (idle mind is a devil’s workshop)

Statistics

The PPKP was new to the department and had not yet accessed the data. Of hand he says the cases here do not extend beyond 15/year and last year’s mortality were 3 individuals. The prevalence is concentrated on men and individuals above 40 especially among odd-job workers and rubber tappers. The PPKP suspects a clinical iceberg exists especially among migrant workers especially illegal ones but there is no budget provision to test them. Common high risk behaviors here include IDU and sexual contact (heterosexual and MSM).

The strategies of this programme

Existing programmes (DHO)
1. National AIDS Strategy [PROSTAR, methadone clinic, condom distribution, organizing health campaigns and screening in high risk areas: Voluntary anonymous screening (IC, phone number, address)]

WE GO TO THEM
2. Pre-marriage HIV testing
3. Handling AIDS Corpses

Under State Health Plan of Action 2011
1. NSEP in KKs in all DHOs (at least 1 KK/DHO)
2. Methadone clinic (2 KKs/district)
3. Improve HIV screening among husbands of pregnant mothers, high risk groups – from prepregnancy care, positive STI, transgendered individuals, sex workers, men-who-have-sex-with-men (MSM), GROs and their partners.

Personnel involved and their responsibilities (organization set up/ duties and responsibilities) DHO

1. PPKP Jamalul Hayat: Manages the HIV/AIDS as well as STI programme (campaigns/collaborating with KKs) in the district, PROSTAR, contact tracing handles AIDS corpses.

MOH: Diagnosis, treatment, counseling, treatment defaulter tracing
1. FMS/MO
2. Lab staff
3. KK – SN/MA in charge of the programme in their health facility

Implementation of activities from District to peripheral level PPKP coordinates with MOH people (through staff in charge in the KKs)

1. Collaboration with NGOs, RISDA, UMNO, AADK, PLKN, schools (HM/HEM)
2. Innovative HIV screening- to know the high risk village first before conducting screening (going in guise of working to know the population e.g. Mat Rempit, targeting screening)
3. Methadone clinic
4. Outreach – Brochure/souvenir with prior explanation at public places, cooking activities
5. PROSTAR – Schools
6. PLKN – Sex education: Using a condom properly
Maintenance of records and reports ( flow of information from peripheral to Ministry level) Open Case  e-notifikasi by PPKPK  MOH
(refer Health Infrastructure)

Budget provision
> HIV/AIDS STI programme: RM 40 000

> Methadone Clinic: RM 30 000

> Programme monitoring and evaluation (challenges/remedies/future programmes) Indicators of State Health Plan 2011 with targets:

1. Improving coverage of Harm Reduction in KKs
a. Number of registered clients (100/KK)
b. Percentage of regular clients (>70%)
c. Percentage of needles returned (>70%)
d. Percentage of clients screened for HIV/TPHA/Hep B/Hep C (100%)
e. Percentage of clients testing positive for HIV/TPHA/Hep B/Hep C (>10%)
f. Percentage of clients receiving advice on safe sex (100%)
g. Percentage of clients receiving condoms (100%)
h. Number of Harm Reduction training sessions conducted (1/year)
2. Methadone clinic (MMT) coverage
a. Number of KKs with MMT (2/DHO)
b. Cumulative registered clients (100 – 150/KK)
c. Percentage of regular clients (>70%)
d. Percentage of clients screened for HIV/TPHA/Hep B/Hep C (100%)
e. Percentage of clients testing positive for HIV/TPHA/Hep B/Hep C (>10%)
f. Percentage of clients receiving advice on safe sex (100%)
g. Percentage of clients receiving condoms (100%)
3. Increasing HIV screening among high risk groups
a. Percentage of pregnant mothers screened for HIV (>50%)
b. Percentage of HIV screening among partners with an MMT client (100%)
c. Percentage of STI cases confirmed for HIV (100%)
d. Percentage of IDU & partners screened for HIV under AADK monitoring
e. Number of activities with transgendered individuals, MSMs, sex workers and other high risk groups (2/year) and their percentage of HIV screening (100%)

Problems
1. Lack of cooperation due to stigma (fear of sending to prison for IDUs)
2. Asymptomatic phase
3. Screening for high risk groups only
4. No funding for illegal immigrants
5. Defaulting treatment (a cumbersome process: KD census and tracing all pseudonyms)
6. Contact tracing/defaulter tracing because of fake addresses and phone numbers
7. NSEP in KK Jeniang had to be postponed – IDUs found problems with the needles offered as they were too big and had to be returned to PharmaNiaga
8. Ineffective PROSTAR – youths indulging in high risk behavior because of the lack of activities

Future Plans
1. Opening a PROSTAR centre equipped with CC/gym/jamming room/karaoke/kitchen
2. HIV/AIDS specific campaign in Kampung Siam at the Wat with a Siamese IK to overcome language barrier

HIV Diagnostic Protocol in Kedah


>Rapid test
---->Non-reactive : F/U 3/12, 6/12
---->Reactive : ELISA/EIA/EA
:a. Positive:
> Repeat
> Confirmed and open case
:b. Negative: STI screen



Managing a HIV Case

1. Open case
   
2. e-notifikasi
   
3. Appointment with FMS at the nearest KK (WE GO TO THEM POLICY): Date, time, caregiver, contacts must be brought along  Counseling and Treatment  F/U by MOs (Clinical side)

**AIDS Corpse Handling Need to inform PPKP/PKD/KD/KK/Hospital. An offense under CDC Act if not done so.

1. Disinfectant used: Sodium hypochlorite/detergent
2. PPKP wears double layered PPE.

Principle: DO NOT INTERFERE WITH CEREMONIAL RITES. Just add on.

Muslim:
Body  Kain kapan with disinfectant  Thick plastic sheet  6 layers of cloth without disinfectant (Corpse becomes big and stigma ensues)

Non-muslim:
Cremation: Clothes soaked with disinfectant and all orifices covered with cotton soaked with disinfectant to prevent fluids leaking out.

Unclaimed bodies are handled by PPKP.

Methadone Substitution Clinic Started in 15/11/2008
Under DHO (Dr. Ishak), FMS (Dr. Amilene), SN Zahrah, Senior MA, KJK, JM.

• Aims to reduce HIV infection among IDUs.

**Only targeted at IDUs (heroin).

Two objectives:
1. Methadone Substitution (2 years)
2. Social integration (Kelab Kembali Bersinar): Getting them a job, helping them start a business, preventing relapse (For life)

Once enrolled, a participant is subjected to blood investigations (LFT, HBV, HCV, TPHA, VDRL, HIV screening) and is referred to the FMS. A date is given for induction. Participant has to bring next-of-kin to the induction. Methadone is a red syrup given at a special room by the Pharmacy Officer who also counsels. After induction, participant is allowed to rest at the facility for 3 – 4 hours and is accompanied back home by kin. Methadone is started at 20 mg and raised to 70 mg and under the FMS’s advice is tapered down.

Other activities in this clinic: safe sex education, screening for STIs, condom distribution

Expulsion from programme (6/64):
a. Urine test is done after 1 week after therapy (If +ve 3 times thrown out of the programme)
b. Poor attendance
Problem initially: Gaining acceptance from the community.

Achievements in the programme in Sik:
1. Businesses started (Agriculture, car workshop, chips business, landscaping, gravediggers, artwork)
2. Community treats the community (Peer recruitment and counseling)
3. Acceptance


RavivarmaRao

Day 8: The Fate of WATER: From The Beginning to The End

As the afternoon’s session gets started, we have been briefed by Encik Azri, who is in-charge of the Bekalan Air dan Kesihatan Alam Sekitar (BAKAS) Unit, regarding the role of Unit BAKAS in the society. It is to reduce the incidence of infectious diseases caused by the environmental conditions (ie. No clean water supply, without sanitary system) by improving or providing a proper water supply and sanitation system.

From The Beginning...

Due to the unfavoured geographical condition in Sik District, a proper water supply system is limited. Hence, most of the water supply provided to the people is through the Gravity Feed System, though the JKR Ministry had started to build more water pumps for the future needs of the people here. According to Encik Azri, in Sik District, there are a total of 17 Gravity Feed System which are notified by the unit and around 30s’ which are built by the villagers and without the notification from the unit.

Locations of The Gravity Feed System (notifited) in Sik

How does a Gravity Feed System work?
Gravity feed is the use of earth's gravity to move something (usually a liquid) from one place to another without a pump. In the terms clean water supply, the Gravity Feed System is a system which in used the gravity force to draw the clean water from a higher areas (water fall, lake…) to a lower ones (villages) and kept for daily usage. However, the water is not treated.

15 years old Hand Pump

On the other hand, hand pumps are still widely in used in the rural areas especially in the sub-district, Sok. There are various types of hand pumps system, but in Malaysia, deep well type is the generally applied type. The installation of a hand pump needs the close mutual aid between both the Unit BAKAS and the villagers.

Firstly, the application must be approved by the District Health Office, and followed by the surveillance of the BAKAS Unit. It is to ensure that the hand pump site is safe, productive, and it is at least 15meters in diameter away from a probable sanitary tank. After the fixation of the site, the villagers will start to construct the root of the pump by digging 15 meters deep into the ground. After that, the BAKAS Unit will establish the system and install the hand pump to the site. A hand pump can supply clean water to 4 – 5 families for their daily usage. However, nowadays the role of a hand pump is slowly substituted by the JKR’s water supply.

JKR's Water Supply

Implemented in 2009

** Both of the programmes are supported and subsidized by the Ministry of Health; hence terms and condition must be fulfilled by the applicants in order to be eligible and recruited into the programme.

Terms and Conditions

• Those who are included in the list Program Perumahan Rakyat Termiskin (PPRT) or Development Programme for The Poor.
  
• Groups of poor people who are not included in the list of PPRT - but have a family income of RM 350.00 and below per month.
• The elderly, single women and disabled
• Houses in the area capable of an outbreak of food-borne diseases / water.
• Low-moving society that found the health education activities are still not able to change the attitude to build its own sanitary facilities.

Surprising fact of Sik:
Sik owned one of the 4 dams in the Kedah State, the Beris Dam, yet there is still insufficient of water supply. Why?

Explanation:
1) Geographical condition
2) Supply irrigation water to southern Kedah and raw water to Penang.


to be continued...

On Sanitation and Waste Product Disposal



Kenny Lim

Day 8: Water Essential

It was a wonderful privilege for us to meet the Drinking Water Quality Control Unit of Sik, which is also known as Kawalan Mutu Air Minum (KMAM), led by Health Inspector, Nor Hazimah Binti Hassan. Together with Bekalan Air dan Kebersihan Alam Sekitar, KMAM has formed a body under the supervision of Engineering Unit of Disease Control Unit. The objective of forming KMAM is to improve the public health standard through regulation of the quality of drinking water in order to reduce the incidence of water-borne diseases. And, its function is to ensure the quality of drinking water by surveillance. Thus, together with its objective the unit served its 5 main elements to ensure the quality of drinking water; which are monitoring, cleanliness survey, evaluation of data, treatment action and institutional inspection.

Sik district is divided into 4 main courses based on its water supply. The courses are Batu Lima, Sik, Jeniang and Beris Jaya. On the other hand, this unit covers 44 point stations for sampling throughout the district. And, the sampling is done weekly and 6 samples will be collected from each station. After the collection of samples, these samples will be sent to Chemistry Laboratory in Alor Star for analysis and the result will be expected after 2 weeks. In terms of water sampling, the quality of water is based on the compounds and chemicals present in it. These compounds are divided onto 4 groups Group 1 (microorganisms), Group 2 (non- metals i.e. ammonia, nitrates), Group (heavy metals) and Group 4 (pesticides).

All the results and data on water sampling done by the KMAM unit will be inserted into a software programme called Water Quality Surveillance (WQS). This database is online-based therefore it can be studied by state level KMAM at all time. Besides the routine water sampling, the KMAM unit also responds to complaints from public and also when there are cases of water contamination.

In addition, Health Inspector, Nor Hazimah has demonstrated water sampling at a station in Sik. Samples of water were taken in 4 different reagents added to them covering the 4 main groups as explained above. Another 6 samples were taken into ‘whirl bags’ for laboratory analysis. She had also demonstrated for us the usage of pH meter, Turbidity meter and Chlorine residue measuring device. The normal limits of some of the measurement taken from a water sample, Chlorine residue:0.2mg/ml,pH:6.5–9, Colour unit: less than 15 and NTU: 5 (turbidity unit).

It was a marvelous exposure to us where we can experience the actual field work instead of theoretical visualisation in the delightful air-conditioned room. Last but not least, we would like to thank Cik Hazminah for spending her precious time with us and giving us such an interesting session.


Kenny Lim

Day 7: Epidemiology of Tuberculosis

Source: IK Jamal Osman of Communicable Diseases Control (CDC) Unit, Sik DHO; MA Alimin, KK Jeniang

Either by clinical iceberg or the lack of people, tuberculosis is not a major public health problem in Sik district. Hence we had an informal session with IK Jamal and MA Alimin regarding this topic.

The prevalence of TB in 2010 was 31 reduced from 45 of the previous year affecting mainly locals. As far as Sik is concerned no major trends are observed in disease epidemiology. Sputum negative cases are rare (three last year) while HIV infection is 5%; seen in the younger age group (20 + years). There was a 2% mortality rate with no MDR, XDR and paediatric TB. The last case of paediatric TB was in 2006. There were no cases of failure, relapse or reinfection last year. An improvement on the whole compared to the previous year.

However the major problem in this seemingly rosy data is the low case detection rate which 68% (not up to the 70% case detection target). The lack of awareness and a focused TB programme is suspect even when resources like medicines are sufficient and funded centrally as well as referrals to the Chest Clinic which operates periodically in Sik Hospital.

The DOTS coverage is 100% although in KK Jeniang the few patients seen there complain of transport issues to the healthcare centre and the prolonged duration of treatment. The side effects of treatment sometimes lead to defaulters. Contact tracing also becomes an issue as at times the index case in a population could not be traced.

TBIS
Refer to Health Infrastructure blogpost by Cassandra.

Contact Tracing
The procedure for contact tracing would to visit the home and workplace of the case and note if they are symptomatic and giving them referrals for a sputum test or CXR. If they fail to comply a warning notice is issued and further similar behavior can result in legal action.

Investigating a TB death
The cause of death would be analysed to ascertain it was a TB mortality. A visit to the individual’s home by the FMS and MA is in order to examine the death certificate and interview the caregivers.

Current Directions
As of now, there is a TB diagnosis and treatment room in the KKs in which each patient’s detailed record is managed as per TBIS as well as drugs are stored according to their doses individualized to the patient. Each patient has a file containing follow-up details, side effects monitoring, notification, treatment course and plan and investigations. A patient’s series of CXRs are also maintained.

The current high prevalence of diabetes has also resulted in TB screening in diabetics as they are prone to be immunocompromised which leads to active TB.

However as with diarrheal diseases, there appears to be no specific programme targeted on TB and mere health education programs carried out by the Health Promotions Unit. The reported low case load is behind this. Although in the Health Plan of Action for 2011, case detection rates and DM TB screening is expected to be made priority and this would work towards better management of this disease.


RavivarmaRao

Day 7: Epidemiology of Diarrheal Diseases

Source: IK Jamal Osman of Communicable Diseases Control (CDC) Unit, Sik DHO

The CDC in Sik is under the umbrella of the Health Inspectorate and is manned by IK Jamal and a PKA (General Health Assistant).

Diarrheal diseases form the epicenter of the CDC in Sik District. This focus may be surprising to a few as it doesn’t extrapolate to other wealthier states in Malaysia where food and water borne diseases have taken a backseat to other communicable diseases like TB and HIV. The paradox is attributable to the lack of clean water supply (most of the water from Sik’s three dams are channeled to Kota Star and Kuala Muda), sanitation services, migrant population and the general poverty in the district (being the poorest but second largest district in Kedah).

The diarrheal diseases which come under the purview would be Acute Gastroenteritis (AGE), food poisoning, cholera, typhoid, dysentery and Hepatitis A. Fortunately in the previous year the last four were zero in incidence though suspected typhoid (2) and dysentery (10) cases were ruled out. However outbreaks of the first two were there and their investigation closely ties with Outbreak Management (refer to the blogpost by Karyn). There were no diarrheal deaths. Diarrheal diseases strike mostly in institutions like training institutes, schools and hostels.

A typical return for AGE would be the above. They are done on a weekly basis. Most outbreaks occur during school holidays (all the spikes correspond to this) when people hosts feasts. Spike 1 would be the March school holidays, Spike 2 Hari Raya and Spike 3 Hari Raya Haji. The lack of a proper industrial kitchen and cooking in open spaces along with the exposed food volume and unsanitary food handling seem to translate into the above figures. The other occurrences are plainly attributed to improper food storage where food is often cooked 9 hours before serving as in hostels and the Food Supplement Programme.

Though it comes as a surprise that no specific programme is conducted routinely to address the issue of diarrheal diseases and the interventions are based on the causes identified by outbreak investigation and managed by the Health Promotions Unit. Typically food handlers are subjected to a food handling course especially at hostels and schools. The State Health Department is often involved in this. Furthermore AGE monitoring is collated with the similar time frame of previous years i.e. comparing incidences of the same week between a run of 5 years. This gives a better picture of management and control of the problem as well as to highlight the need for newer interventions.

Even so, the indicators used in the 1990 Revised WHO Diarrheal Control Programme are not monitored here. The difficulty in monitoring these indicators and lack of deaths seem to be the reason though other indicators of food quality control (premises) are used. It is unique to note while in global guidelines the identification of the organism is not a priority, here it is otherwise where stool samples (if obtainable) are cultured and interventions are specific to the organism. An example would be proper food storage in case of Bacillus cereus.

Unfortunately managing diarrheal diseases remain a challenge. The average number of AGE cases in Kedah have exceeded the maximum average and is identified in the Health Action Plan of 2011. The difficult in obtaining stool samples as well as the attitude of the public superimpose on inherent factors. These stem on socioeconomic reasons as most cases are institutional and a reporting-co-investigation could possibly bring disrepute and loss of tenders.

Hence, future intervention should tie in a continuous programme to address the inherent problems (collaboration with BAKAS to improve water and sanitation) and food handling practices to institutions with regular auditing.

RavivarmaRao

Day 7: Disease Surveillance & Outbreak Investigation

CDC: Disease Surveillance & Outbreak Investigation

The cases are collected and compiled from 4 facilities:
a) KK Jeniang
b) KK Gulau
c) Casualty of Sik Hospital
d) OPD of Sik Hospital

Job responsibilities:
a) Surveillance
b) Analyze data
c) Investigate the cause
d) Come out with plans to control the disease
e) Take specimen
f) Prepare report
g) Take orders from superiors

The diseases that are controlled:
a) Food & water borne diseases
b) Vector borne disease
c) Vaccine Preventable Disease
d) TB, leprosy
e) STD
f) HIV/AIDS
g) Zoonotic disease
h) International health
i) New diseases : SARS, H1N1

Notifiable Communicable Disease in Malaysia
a) Notification by phone followed by written notification (within 24 hours)
- Dengue fever & dengue haemorrhagic fever
- Yellow fever
- Diphtheria
- Ebola
- Food poisoning
- Cholera
- Plaque
- Poliomyelitis (acute)
- Rabies
- Leptospirosis

b) Written notification within one week after diagnosis
- Whooping cough
- Measles
- Dysenteries (all forms)
- Gonococcal infection (all forms)
- Leprosy
- Malaria
- Myocarditis
- Relapsing fever
- Syphilis (all forms)
- Tetanus (all forms)
- Typhoid and parathyphoid fevers
- Typhus and other ricketsioses
- Tuberculosis
- Viral encephalitis
- Viral hepatitis
- Any other life-threatening microbial infection
- HIV

Types of food and water borne diseases:
a) Cholera
b) Typhoid
c) Dysentery
d) Food poisoning
e) Hepatitis

FOOD POISONING

Definition of food poisoning:
- It is the sudden onset of vomiting/ diarrhea/ other symptoms after eating same food or different food from the same place

In Sik, food poisoning usually occurs in this few locations:
a) School
b) Pusat latihan
c) Hostel
Outbreak of food poisoning
Information needed:
1. Date & time of all the incidents
2. Place where the food is prepared and eaten
3. Similar food and drinks taken by the patients including ice
4. Other types of food which are shared
5. Date and time of onset
6. Symptoms
7. What are the treatments given so far
8. Other factors excluding food

Team needed:
1. Mobile room
2. Investigation team
3. Control and sanitation team
4. Health education team

Steps to control and prevent:
1. Close down the building (Akta KBP 1988) / Akta Makanan 1983
2. Separate contaminated food
3. Separate cause of contamination
4. Separate and treat people with high risk of spread ( food handlers, close contacts)
5. Clean the involved building
6. Clean the area around the building
7. Health education (wash hands etc)

Day 6: We Will Take Care of You

After talks and discussion on CDC topics, PPKP Muhamad Fahmi bin Abidin who is a member of the Non-communicable Diseases (NCD) team came in and gave us a talk on his department. The talk included the duties and functions, job and responsibilities, activities organized, and the operations of the NCD team.

After the talk by the PPKP, I realized that at a District Health Office, the duty of the NCD team does not only limit to Diabetes Mellitus, Hypertension, Asthma and Mental health. In fact, chronic diseases like Diabetes Mellitus and Hypertension (from screening to treatment to data

recording) are usually managed at the level of the Klinik Kesihatan (KK).

The other duties of NCD include enforcement of tobacco regulation (e.g.: illegal trade, smoking at non-smoking areas and underage smokers) with operations regularly. There is also a ‘Quit Smoking Clinic’ at KK Jeniang which operates every Thursday from 8am to 3.30pm. They deal with individuals who want to quit smoking and as well as referral cases (underage students who are caught in the Operations).

The NCD team also performs BMI index screening on their staff and Form 3 students at school. Staff who are overweight (BMI >27.5) are required to join the ‘Lose Bodyweight Programme’ which includes aerobics and outdoor activities.

Surprisingly, the NCD team is also in charge of the health and safety of nurseries and kindergartens. This includes disease outbreak such as hand foot mouth disease as well as the safety of the environment around nursery and kindergartens.

Day 5: Prevent is Better Than Cure: Dengue, Malaria and Filiarasis

Today was another great Sunday morning which after we had our breakfast, all got assembled at the DHO for a lecture by Mr. Mohd Zahid, a Health Inspector with 15 years of experience in Vector Borne Disease Unit, DHO Sik. We were first introduced to the organization chart, vision and mission of the unit. Under the unit, there are Dengue and Malaria team which consisted of 2 people each.

We were also informed that Sik is a district endemic to dengue while Malaria is mainly introduced by foreign workers working in the agriculture industry. Filiariasis on the other hand were monitored by the Malaria unit under Active Case Detection(ACD) due to it's rarity in this district. According to Mr. Mohd Zahid, Chikungunya was a major problem during late 2008 to 2009 as many were involved. There were no major outbreaks in Sik for the past 2 years.

Among the activities carried out by the Dengue unit here in Sik were:

- Dengue Survey - Done usually in the morning when cases were reported
- Fogging - Done in the evening unless raining with Malathion
- Abating
- Larvaticide
- Law Action - Under Vector Destruction Act 1975
- Active Case Detection

Activities in the Malaria Unit includes:

- Monitoring areas abundant with foreign workers - Especially Depot Tahanan Imigresen Belantik.
- BFMP Slides for case detection
- ACD/PCD
- Focal spraying
- Medicated Nettings

We were also briefed on Aedes Survey Procedure done as routine here in Sik to minimize the cases of Dengue infection in this district. Then, we were introduced to the notification system used by the Ministry of health known as e-Dengue where details of cases detected in hospitals and clinics will be notified to the DHO through this online network.

After the briefing session, we were brought to a Kampung Masjid, 30km from Sik Town, to have an overview of how the field survey was carried out and how the sample was taken for lab investigation after the mosquitoes larvae were found. We were also told that only if more than 5 larvaes are found, one can be compounded. It was a whole new exposure for all of us.

In the afternoon, we were given a demonstration on the mixtures of fogging solutions and the equipments used during fogging activities. Ansingke charge of 200 Ml Malathion 96T can be used to fog 4 to 5 houses. For large residential areas where roads were easily accessible, larger machine known as the ULB is often used.

The day ended with a visit to the Imigration Detention Depot at Belantik.


Shaun Ng Chong Sian

Day 4: Excellent Primary Healthcare Services in Sik!

A session with Senior Assistant Medical Officer Mr. Jurid

Firstly, Mr Jurid explained briefly about healthcare system in Sik District



Two types of Facilities

• Healh Clinic (KK)- For 15,000 – 20,000 people provides all the 8 essential health services, plus dental care, and has expanded the scope further to include elderly health, adolescent health, mental health, etc.

• Community Clinic (KD)- For 3,000 – 4,000 people run by two Community Nurses (Jururawat Masyarakat) & specially trained midwife provides maternal and child health service, and outpatient treatment of minor ailments.

Then he continued with his topic, primary healthcare services…

Vision of primary healthcare services
Primary Health Care is the thrust of healthcare services towards healthy families and quality of life

Objectives of primary healthcare services
1. Strengthen and integrate the preventive activities and risk assessment of diseases, management of acute and chronic communicable diseases and NCDs, limitation of disabilities and diseases rehabilitation through quality primary health care.
2. Strengthen and increase community and private sector cooperation and involvement
3. Plan and manage staff development in line with the needs of primary health care services.
4. Plan and coordinate technical support services to enhance the quality of primary health care services.
5. Accessibility of integrated, comprehensive and quality telecare services in continuous and borderless form via internet and ensure medical specialist services is in proximity with clients.
6. Cooperate with government agencies and NGOs in the utilization of IT system

A) Primary Healthcare Activities

• Outpatient treatment services
• Reviewed approach in KK

• Medical services for chronic diseases and
• Periodic Family Medicine Specialist services
• Quality Assurance Program (QAP) for family health
• Advisory Panel for health clinic – a good example of community participation in primary health care
• Monitoring of E-masa – Malaysian government trying to reduce ‘waiting’ period in clinic
• After hours clinic services –mainly for emergency treatment
• Emergency ambulance services

B) Special Programs (Expanded scope)

• Geriatric/ Senior citizen services
• Mental health services
• Adolescent health programs
• Health services in National Service (PLKN) centres

C) Social Services

• Rehabilitation services at home
• Health Camp – provides health screening services
• Elderly Exercise Activity

Evaluation of primary healthcare services are done based on

• CPG (Clinical Practice Guidelines)
• SOP (Standard Operating Procedure)
• QAP (Quality Assurance Program)
• KPI (Key Performance Indicator)

Besides, Encik Jurid also explained briefly about the budget allocation for each health clinic. Since there are only 3 health clinics in Sik, each clinic receives a huge amount (these figures depend upon allocation made by Sik District Health Office and State Health Office). Therefore, the services provided in Sik can be considered excellent.

Dineash Kumar

Day 4: Fitness First!

We started our day today, 8.30 am at the DHO. We were waiting for the DHO staff to guide us to Hutan Rekreasi Lata Mengkuang . All of us were excited to go there to participate in the Weight Reduction Programme which was organized by the Health Promotions Unit along with the NCD Unit. The budget for the programme was sponsored by the State Health Department.

This programme is conducted 3 times per year. The objectives are:

1 .To reduce the body weight of the staff to ideal

2. To reduce the complications due to obesity

This programme is targeted at the staff whose body mass index (BMI) is more than 27. The staff selected will be informed earlier and attendance is mandatory.


Once we reached there, the participants were warming up and doing aerobics. They were due to start an Explorace. Miss Azizah bt Din, the nutritionist in charge was explaining the rules to the participants. We were asked to split into two groups and head to two checkpoints.

As soon as we reached our checkpoints, we assisted the officers there in organizing the games as well as cheering for the participants.

However we were not able to stay there till the activities ended because we had a talk back in the DHO and we drove back at 11.

Vijayananthini

Day 3: Eat Safe, Stay Healthy

Today, we started with a brief introduction with Dr. Ishak, and followed by a talk on nutrition with the nutritionist, Azizah Bt. Din.

We are glad to know various activities being done to treat as well as to prevent nutritional problem in Sik.

For instance, RMT (Rancangan Makanan Tambahan) for the school children, Food Basket for the underweight children, weight management programme and Healthy Kitchen for adults (was really interesting to know that they teach and demonstrate the participants how to cook healthy food besides educating them on the importance of weight control.), Nutrition Month on April annually, Breast Feeding Month and so forth.

She was very informative yet friendly. After the formal talk, we had an informal chit chat with her about Sik. WE were more concerned to know the eating places in Sik. We were given a few suggestions and end up in knowing that there is a vineyard in Sik!!

Our unbelievable mind caused us to drive heading to Beris (where the vineyard situated) which was about 10kms from DHO Sik during our lunch break.

It was really a mind blowing to visit such a beautiful place (in Sik).

After having lunch, we got into the meeting room for our next session. to be continued...

Hemala

Day 2: Do You Know?..in Sik, We Have VIA!

Visual Inspection with Acetic Acid (VIA)

Person in-charge: Sister Aminah in KIA Sik

Visual Inspection with Acetic Acid (VIA) is a screening test for early stage of cervical cancer (secondary prevention).

VIA screening test is available in all primary health clinics in Sik District. We were informed that this is a pilot project in Malaysia and the MOH Malaysia wishes to continue VIA screening test services in this district due to high demand (>3000) from local woman.

Sister Aminah mentioned any sexually active women aged 20-49 can undergo VIA test in clinic anytime and the test would not be carried out on pregnant women and during menstruation. The test is done by performing a vaginal speculum exam during which a health care provider applies dilute (3-5%) acetic acid (vinegar) to the cervix. Abnormal tissue temporarily appears white when exposed to vinegar (ie. It appears like mosaic pattern)


Why Acetic Acid?
It dissolves mucus and induces intracellular dehydration which results in protein coagulation. As a result, cells with increased with nuclear/ cytoplasmic ratio, nuclear density and chromosomal aneuploidy.

VIA test result categories
If Negative,
No colour change on the cervical surface. Follow-up after 3 years

If Positive,
There is an acetowhite colour change on the cervical surface. Refer to Specialist Clinic for confirmation of cervical cancer through colposcopy.

There is no known side effect from VIA test except little discomfort during the procedure.

Click the reference chart for VIA findings

Dineash Kumar

Day 2: Mothers, We Care About You and Your Child...

As guided and arranged by Mr.Hamzah from the DHO, we visited the local court to learn the judicial procedure in dealing with food safety cases.This is the first time everyone went inside a court and none of us were familiar with the environment and situation inside.

The coming second activity of the day is visiting the Maternal Child Clinic which was attached to the DHO. This tour of KKIA (Klinik Kesihatan Ibu dan Anak) was guided by Sister Sitiaminah. This clinic provides special care for women ranging from pre-marital, antenatal, and postnatal services. Basically the system is similar throughout the whole Kedah; regular visiting which consists of serial parameters monitoring related to pregnancy. Special thing in Sik is that it is the only district which provides VIA (Visual inspection with Acetic Acid). Sister Siti allowed one of our female students to observe VIA, but unfortunately,there wasn't any procedure done during that day. Also,they have a special tagging system for women. Each record is attached with strings of different colours which represent different indications. Red colour is for Pregnancy induced hypertension; green string is for Gestational Diabetes Mellitus and orange string is for Bronchial asthma and others.

In the child clinic,regular routine follow up consists of measuring height/length and weight, developmental assessment done by nurses or MO, as well as nutritional assessment. Kids can receive various kinds of growth and developmental monitoring services here,as well as vaccination.A chart is prepared for every single child. As long as body weight is detected below average, medical personnel will advice on diet adjustment. In advance, they also provide food baskets to children whose family income is low or unstable. Vaccination and details about how a cold chain works in preservation of vaccines were discussed as well.

We ended our day with a visit to the local Pusat Pemulihan Dalam Komuniti. We were invited to go along with the nurse as well who was doing her routine visit. We were briefed by the teacher, with information about the PDK: organization, daily activities, special activities and facilities. There are around 8 teachers, 38 trainees and 60 students (20 of them not able to move) in this PDK. On beginning of the day they have a morning assembly and proceed to daily activities. Here, the child is taught how to live independently.

Once they are capable of doing this, they will be referred to a Special School. This PDK also has their own van and is used to fetch children if required. Physiotherapy services are also provided by a trained worker. They also have a physiotherapy pool,which is located at the back of the center. One focus on special activities is some of the kids around here are able to make some handicrafts which can be sold. They also have field trips each year, recently to Cameron Highlands.The budgeting is under the Welfare Department. However the success of the programme depends on the cooperation given by the caregiver.

Tan Chai Yih

Day 1: Back to School!

We were then given a talk on the School Health Programme in Sik District by Jururawat Kesihatan Zainab Warib- and she explained on the district health office's role in maintaining the health of school children, in particular focus today of secondary school children.

The School Health Unit falls under the Matron’s purview of duties and consists of 2 Staff Nurses, 2 Community Nurses, 1 Sister, 1 Medical Assitant and 1 driver. The unit aims to give optimum health services to the schools here (9 secondary schools, 22 primary schools, 33 kindergartens, 17 PASTIs and a PDK). Their activities include immunizations, simple treatment for the common skin diseases and coughs and colds, offering referrals to Sik Hospital as well as the Visual Acuity Test for early intervention. They are also involved in the Doktor Muda Programme and PROSTAR.

We were extremely lucky as the sister then invited us to follow her and her team to administer the HPV vaccinations for the Form 1 students in Sekolah Menengah Agama Sik, a fully residential school.

We followed the sister and her team to the school, which was just about a 5 minute drive from the health office. It's quite a large school, with the infrastructure up-to-date and complete.

The school has 2 “bilik sakit”s - where health related procedures are carried out- and it has informative posters regarding dengue, skin disease and other common problems on the wall to provide information to the children.

The sister then briefed us on how they go about administering the vaccines- importantly, the consent form MUST be signed by the guardian, or else, they do not give the vaccines.

The type used is 'Cervarix', which costs about RM 75 per dosage, and its given for Form 1 and Form 2 female students, who have to complete the 3 dosages at 0,1 and 6 months.


The nurses take extra precautions as well, by making sure the students rest for about 5-10 minutes, to make sure the vaccine does not cause them to suffer any harmful side effects.

A brief interview session was also conducted with the teacher in-charge: Pn Faizah Ibrahim.
According to her, the major health issues in the school were skin diseases (scabies, rashes and so forth) as well as URTIs.

As such, the school is planning to invite health officials to give talks on these two topics, as well as on how to maintain personal hygiene and cleanliness.

When probed further, we found out that the school apparently has no incidents of smoking, drug or alcohol abuse or moral promiscuity. There were no serious social issues in the school, according to the teacher.

Nithiyia