3.Pencegahan Pneumonia.pdf

Hari Pneumonia se-Dunia ke X
12 November 2018
Pencegahan Pneumonia

Bahayanya pneumonia
Fungsi paru  oksigen
jaringan paru rusak
oksigen kurang
kematian

15 negara dengan kematian akibat
pneumonia terbanyak di dunia
Sumber:
One is too many: ending child deaths from pneumonia and diarrhea. UNICEF. 2016.

No Causes of Death (ICD 10), 0 - 11 months %
1
Disorders relating to length of gestation
and fetal growth (P05 – P08)
18.9
2
Intrauterine hypoxia and birth asphyxia
(P20, P21)
14.8
3 Pneumonia (J12 – J18) 9.7
4
Diarrhoea and gastroenteritis of presumed
infectious origin (A09)
9.2
5
Congenital malformations of the heart
(Q20 - Q24)
5.8
6 Respiratory distress of newborn (P22) 4.3
7
Fetus and newborn affected by maternal
factors and by complications of pregnancy
labour and delivery (P00 – P04)
2.4
8 Meningitis (G03) 2.2
9
Haemorrhagic and haematological disorders
of fetus and newborn (P50 – P61)
1.7
10 Diseases of the digestive system (K56) 1.4
Pneumonia Penyebab Kematian Utama pada
Usia 0 - 11 bulan dan 0-59 bulan
No Causes of Death (ICD 10), 0-59 months %
1
Disorders relating to length of
gestation and fetal growth (P05 – P08)
14.0
2
Diarrhoea and gastroenteritis of
presumed infectious origin (A09)
11.1
3
Intrauterine hypoxia and birth asphyxia
(P20, P21)
11.0
4 Pneumonia (J12 – J18) 9.5
5
Congenital malformations of the heart
(Q20 - Q24)
5.9
6 Meningitis (G03) 3.5
7 Respiratory distress of newborn (P22) 3.2
8
Accidental drowning and submersion (W65
– W74)
2.0
9
Fetus and newborn affected by maternal
factors and by complications of
pregnancy labour and delivery (P00 –
P04)
1.9
10 Diseases of the digestive system (K56) 1.5
4
The National Institute of Health Research and Development-Ministry of Health Republic of Indonesia. Indonesia Sample Registration System 2015. Lembaga Penerbitan
Balitbangkes. 2017: pg.21 (2)

Kematian karena Pneumokokus dan Hib pada anak usia 1–59 bulan

Cakupan vaksin penting terkait pneumonia
Meningkatnya cakupan intervensi yang berimpak tinggi dan
penguatan sistem kesehatan merupakan faktor kunci
penurunan angka kematian balita
Dosis ke-3 vaksin Hib Dosis ke-3 vaksin PCV
UNICEF. Committing to Child Survival: A Promise Renewed Progress Report 2015.

CVD=cardiovascular disease; IPD=invasive pneumococcal disease.
1. Offit PA, et al. Pediatrics. 2002;109:124-129. 2. Garcia-Rodriguez JA, et al. J Antimicrob Chemother. 2002;50(S2):59-73. 3. Caruso C, et al. Immun Ageing.
2009;6:10. 4. Kyaw MH, et al. J Infect Dis. 2005;192:377-386. 5. Musher DM. Streptococcus pneumoniae. In: Mandell GL, et al, eds. Mandell, Douglas, and
Bennett’s Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, PA; 2010:2623-2642.
6. Bewick T, et al. Thorax. 2012;67:540-545.
Mengapa Kelompok Usia Muda Berisiko terhadap IPD
dan Penyakit Pneumonia akibat Pneumokokus?
Anak usia <2 tahun
•Menurunnya antibodi yang didapat dari Ibu saat lahir1
•Sistem imun yang belum matang1
•Kolonisasi kuman Streptococcus pneumoniae nasofaring yang tinggi2
7

Framework Pengendalian Pneumonia

Lindungi
• ASI ekslusif selama 6 bulan
• Nutrisi yang cukup sehingga anak memiliki gizi baik
• Semua BALITA mendapatkan vitamin A 2x setahun setiap Februari
dan Agustus di Posyandu
• Mengurangi polusi asap rumah tangga dari tungku dan kompor.
Bersihkan kompor secara teratur.
• Tidak merokok di dalam rumah.
• Kebiasaan mencuci tangan dengan air bersih

Vitamin A
Cegah defisiensi vitamin A

Anak yang terpapar rokok, 4 kali lebih tinggi
memerlukan rawat inap karena masalah
pernapasan dan 2-3 kali lebih tinggi dalam
hal kunjungan ke gawat darurat karena
masalah pernapasan

Pencegahan:
Hilangkan Faktor Resiko
peningkatan
risiko
pneumonia
ASI (-)
Defisiensi vit A
Berat lahir rendah
Cuaca dingin
Pajanan polusi udara
• Asap rokok
• Asap bakaran biomas
• Polusi udara lingkungan
Imunisasi (-)
Usia ekstrim
Urban/kepadatan
Prevalensi tinggi
karier nasofaring
bakteri yang patogen
Anak banyak
Umur ibu muda
Gizi buruk

Cegah !!!!
• Imunisasi dasar pada bayi terutama DPT (Difteri,
Pertusis dan Tetanus) dan Campak cegah
komplikasi pneumonia
• Pemberian vaksinasi Hib dan Pneumococus pada
bayi dan anak.
• Pemberian zinc pada anak dengan diare.
• Pencegahan HIV/AIDS pada anak
• Profilaks kotrimoksazol pada anak dengan HIV/AIDS

0 250.000 500.000
Pneumococcus
Rotavirus
Hib
Pertussis
Measles
Neonatal tetanus
Chart Title
Kematian akibat Penyakit yang Dapat
Dicegah dengan Vaksin pada Anak
In children younger than 5 years
•S pneumoniae is a leading cause of
severe pneumonia, especially in the
developing world2
•According to the 2015 estimates,
Hib and S pneumoniae were
responsible for close to 65% of
deaths due to lower respiratory
infections1
Estimated deaths in 20151
Penyakit pneumokokus masih menjadi masalah
kesehatan serius pada anak di dunia
Wang H, et al. Lancet. 2016;388(10053):1459-1544. 2. UNICEF/WHO. Pneumonia: the forgotten killer of children.
http://www.childinfo.org/files/Pneumonia
19

20
Haemophilus influenzae
A Gram-negative coccobacillus that commonly
infects the upper respiratory track of children
The polysaccharide, is the primary factor
associated with virulence.
Of the 6 capsular types of H influenzae, type b
(Hib) is responsible for more than 90% of
systemic infections.
Carriage rates in children <5 years varied
considerably from very low, e.g. 0.6%–1.3% in
Taiwan and Hong Kong, to 6%–8% in India and
Thailand.
H. influenzae on a blood agar plate
https://www.who.int/biologicals/areas/vaccines/haemophilus/haemophilus_influenzae_typeb_Hib/en/ 2. Haemophilus influenzae type b (Hib) Vaccination
Position Paper – September 2013. Weekly epidemiological record 2013;88(39):413-28

21
• Bakteri Gram Positif1
• Kapsul Polisakarida1,2
– Faktor Virulensi
– Serotype
– Target Vaksin
• Ada lebih dari 90 serotype1,2
– Belasan serotype berperan
dalam 70% - 93% kasus IPD
secara global3
– Patogen yang biasanya
teradapat di nasofaring1
Streptococcus sp. Chains of nearly-spherical bacteria. From The Rockefeller University.
1. CDC. Epidemiology and prevention of vaccine-preventable diseases. 11th ed. 2009;217-230.
2. WHO. Acute respiratory infections (update September 2009). http://www.who.int/vaccine_research/diseases/ari/en/print.html. Accessed March 16, 2010.
3. Hausdorff WP et al. Clin Infect Dis. 2000;30(1):100-121.
4. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine Preventable Diseases. The Pink Book. 11th Edition. May 2009.
Streptococcus pneumoniae

Kolonisasi Nasofaring
1. Hull MW, et al. Infect Dis Clin North Am. 2007;21:265-282.
2. Cardozo DM, et al. Braz J Infect Dis. 2006;10:293-303.
3. Regev-Yochay G, et al. Clin Infect Dis. 2004;38:632-639.
4.Chi DH, et al. Am J Rhinol. 2003;17:209-214.
Image adapted from: http://www.1911encyclopedia.org/images/f/f4/Olfactorysystem-2.jpg.
OMA
Pneumonia
Bakteremia
Meningitis
Sinusitis Menyebar ke Individu Lain
 melalui droplet,
 Inkubasi 1-3 hari,
periode infeksius selama
organisme ada di sekret
pernafasan
ISPA sebagai predisposisi
CDC - Redbook online 2012
• Nasofaring manusia merupakan tempat tinggal
pneumokokus  berfungsi sebagai reservoir dan sumber
transmisi pneumokokus antar individu.
• Pneumokokus yang tinggal menyebar dari nasofaring ke
jaringan sekitar (otitis media akut, sinusitis) atau menginvasi
pembuluh darah (pneumonia, bakteremia, meningitis)

Karier Nasofaring di Asia
Carriage rate of pneumococci among children from 11 countries.
Lee NY, Song J-H, Kim S, et al, Carriage of Antibiotic-Resistant Pneumococci among Asian Children: A Multinational Surveillance by the ANSORP
CID 2001;32:1463-69
Karier
Nasofaring di
Asia berkisar
9.0 % – 43.2 %

Distribusi Serotipe Pada Pasien dengan
Pneumonia yang Disebabkan Pneumokokus
Serotypes
Gentile et al.
(62)
Bender et al.
(63)
Resti et al.
(64)
Bewick et al.
(66)
Cilloniz et al.
(60)
Desain Study Meta-analysis
Retrospective
Study
Observational
Study
Prospective
Observational
Study
Prospective
Observational
Study
Periode Study (Thn) 1980–2008 1997–2006 2007–2009 2008–2010 2006–2009
Wilayah Study
Latin America
and Caribbean
US Italy UK Spain
Usia Populasi Study <5 Yr <18 Yr 0–16 Yr ≥16 Yr
Adult (Age Not
Specified)
Jenis Pneumonia CAP Pneumonia Bacteremic CAP CAP Invasive CAP
Serotypes 14 (33.0%) 1 (22.6%) 1 (32.5%) 14 (18.6%) 1 (32.1%)
1 (11.0%) 3 (11.3%) 19A (15.0%) 1 (16.5%) 19A (17.9%)
5 (10.8%) 19A (10.5%) 3 (12.5%) 8 (14.5) 7F (6.0%)
6B (7.4%) 14 (5.6%) 5 (6.2%) 3 (8.3) 14 (6.0%)
15C (5.2%) 6B (4.8%) 19F (6.2%) 19A (8.3) 5 (4.8%)
19A (4.7%) 19F (4.8%) 14 (3.8%) 4 (1.7%) 4 (3.6%)
Song JY, Nahm MH, Moseley MA. Clinical Implications of Pneumococcal Serotypes: Invasive Disease Potential, Clinical Presentations,
and Antibiotic Resistance. J Korean Med Sci 2013; 28: 4-15.

Distribusi serotype dan coverage vaksin pada 42 S.pneumoniae
Isolat karier S.pneumonia anak terinfeksi HIV di Jakarta
Karier Nasofaring pada Anak dengan HIV,
Jakarta
Serotype
PCV13 coverage:
60%
19F
19A
6A/B
23F
11A
9V
sg18
12F
15B/C
3
35B
35F
7F
Untypeable cps-positive
Untypeable cps-negative
Jumlah
8
4
4
3
2
2
2
1
1
1
1
1
1
5
6
%
19
10
10
7
5
5
5
2
2
2
2
2
2
12
14
Safari D, Kurniati N, Waslia L, et al. Serotype Distribution and Antibiotic Susceptibility of Streptococcus pneumoniae Strains Carried by Children Infected
with Human Immunodeficiency Virus. Plos One. 2014;9(10):1-7

• Pada 1,200 anak sehat usia 2
bulan – 5 tahun di Lombok
Tengah
• Karier S. pneumoniae 46%
• PCV13 coverage 56%
Karier Nasofaring pada Balita, Lombok
* Serotype (number): 34 (7); 22F (7); 35F (7); 15A (6); 3 (5); 20 (4); 31 (4); 38 (4); 4 (3); 17F (3); 7F (3); 1 (2); 12F (2); 33F (1); 7C (1); 9V (1).
Serotype
6A/B
19F
23F
15 B/C
19A
14
11A
10A
35B
18
Others*
Untypable
Jumlah Isolat
120
64
58
45
24
20
19
13
10
9
60
115
% Isolat
22
11
10
8
4
4
3
2
2
2
11
21
Hadinegoro SR, Prayitno A, Khoeri MM, et al. Nasopharyngeal carriage of Streptococcus pneumoniae in healthy children under
five years old in Central Lombok Regency, Indonesia. Southeast Asian J Trop Med Public Health 2016;47(3):485-493

Gunungkidul and Sumba Barat Daya
(Eijkman Institute,US CDC Jakarta, US CDC Atlanta, FKUI)
Karier Nasofaring S.pneumoniae overall: 55%
• Gunungkidul: 31.2%
• N=188. Distribusi serotype: 6A/6B, 19F, 3, 14, 23F,
6C/6D, 15B/15C, 34
• Sumba Barat Daya: 84.5%
• N=364. Distribusi serotype: 6A/6B, 19F, 23F, 19A, 14,
11A/11D, 21
PCV13 coverage >50%
Safari D, Daningrat WOD, Khoeri M, et al. Risk Factors of Pneumococcal Carriage in Children Under 5 Years of Age in Indonesia. Poster No.198 ISPPD 11th.
April 2018, Melbourne
Studi cross sectional dengan sample minimum:
432 anak <1 tahun dan 986 anak 1-<5 tahun

Murad C, Dunne, E, Sudigdoadi S, et al. Nasopharyngeal carriage, serotype distribution and antimicrobial resistance genes of Streptococcus
pneumoniae among healthy infant in Indonesia during first years of life. Poster presented in ISPPD 11th, Melbourne 15-19 April 2018
Prevalensi Karier Pneumokokus berdasarkan Umur pada Bayi yang Tinggal di Perkotaan dan
Pedesaan
Karier Nasofaring pada Bayi, Bandung (1/2)
Karier 21.5% pada Enrollment 2 Bulan 
67.3% pada 12 Bulan. Pedesaan > Perkotaan
• 200 bayi sehat belum pernah divaksin PCV usia 8
dan 12 minggu pada Visit 1: 98 bayi dari perkotaan
(Puter) dan 102 dari pedesaan (Jaya Mekar)
• Total 1575 swab dikumpulkan. Ditemukan 314 episode
karier. Prevalensi karier nasofaring meningkat sesuai
umur dalam tahun pertama kehidupan
Universitas Padjajaran, Murdoch Children’s Research Institute, The University of Melbourne,
London School of Hygiene and Tropical Medicine, PATH

Karier Nasofaring pada Bayi, Bandung (2/2)
Distribusi Serotipe pada Bayi Sehat
6A
19A
3

Deteksi Gen Resistensi Antibiotik
Deteksi Gen Resistensi Antibiotik (AMR gene) dengan Microarray
pada Sample yang mengandung Serotype Pneumokokus Tunggal
(N=478)

Karier Nasofaring overall:
• S.pneumoniae: 49.5%
• H.influenzae: 27.5%
• M.Catarrhalis 42.7%
• S.aureus: 7.3%
Dunne EM, Murad C, Sudigdoadi S, et al. OneCarriage of Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus
aureus in Indonesian children: A cross-sectional study. Plos One 2018;13(4): e0195098.
Karier Nasofaring di Padang, Bandung, Lombok
Universitas Padjajaran, Universitas Andalas, Universitas Mataram, Murdoch Children’s
Research Institute, The University of Melbourne, London School of Hygiene and Tropical
Medicine, PATH
Studi cross sectional dengan sample 302 anak sehat usia 12-24 bulan

20 serotype tersering yang diidentifikasi dalam swab nasofaring pada anak
Indonesia usia 12-24 bulan, berdasarkan area
Karier Nasofaring di Padang, Bandung, Lombok
Universitas Padjajaran, Universitas Andalas, Universitas Mataram, Murdoch Children’s
Research Institute, The University of Melbourne, London School of Hygiene and Tropical
Medicine, PATH
Dunne EM, Murad C, Sudigdoadi S, et al. OneCarriage of Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus
aureus in Indonesian children: A cross-sectional study. Plos One 2018;13(4): e0195098.
Cakupan Serotype
PCV13:
Bandung 26/73 (36%)
Lombok 28/53 (53%)
Padang 22/38 (58%)

33
Karier Nasofaring Pneumokokus di Indonesia
Ringkasan
20
Provinsi Tahun Subyek N % positif
Lombok 1 1997 Anak, 0-25 bulan 484 48
Bandung 2
2002-3 Anak, 2 – 59 bulan 1012 60
Bandung 3 2004 Anak, 0-8 minggu 123 11.4
Semarang4 2010 Anak, 6-60 bulan 243 43
Lombok5 2012 Anak, 2-60 bulan 1200 46
Jakarta6 2012 Anak (HIV) 4-144 bulan 90 46
Gunung
Kidul7
2017 Anak, <5 tahun 1008 31.2
Sumba7 2017 Anak, <5 years 814 84.5
Karier nasofaring pada balita, pada umumnya sekitar 46% (31.2%-84.5%)
Serotype paling sering
6, 23, 15, 33, 12, 19
6B, 19F, 23F, 14
19F, 14, 6B, 6C
6A/B, 15 B/C, 11A, 23F,19F
6A/B, 19F, 23F, 15 B/C,19A
19F, 19A, 6A/B, 23F, 11A
6A/6B, 19F, 3, 14, 23F
6A/6B, 19F, 23F, 19A, 14
1. Soewignjo S, Gessner BD, Sutanto A, et al. Streptococcus pneumoniae Nasopharyngeal Carriage Prevalence, Serotype Distribution, and Resistance Patterns among Children on Lombok Island, Indonesia. CID. 2001;32:1039-
43 2. Murad C, Agustian D, de Gouveia L, et al. Serotype Distribution and Antimicrobial Resistance of Nasopharyngeal Pneumococci Among Children < 5 years with Non-Severe Pneumonia in Bandung, Indonesia, 2002-2003.
Abstract WSPID 2009 3.Kartasasmita CB, Murad C, de Gouveia L, et al. Nasopharyngeal Carriage of Streptococcus pneumoniae in Indonesia: Neonatal Acquisition and Intrafamilial Transmission Bandung, Indonesia, 2006 4.
Farida H, Severin JA, Gasem MH, et al. Nasopharyngeal Carriage of Streptococcus pneumonia in Pneumonia-Prone Age Groups in Semarang, Java Island, Indonesia. Plos One. 2014: 9(1):1-3 5. Hadinegoro SR, Prayitno A,
Khoeri MM, et al. Nasopharyngeal carriage of Streptococcus pneumoniae in healthy children under five years old in Central Lombok Regency, Indonesia. Southeast Asian J Trop Med Public Health 2016;47(3):485-493 6.Safari
D, Kurniati N, Waslia L, et al. Serotype Distribution and Antibiotic Susceptibility of Streptococcus pneumoniae Strains Carried by Children Infected with Human Immunodeficiency Virus. Plos One. 2014;9(10):1-7 7.Safari D,
Daningrat WOD, Khoeri M, et al. Risk Factors of Pneumococcal Carriage in Children Under 5 Years of Age in Indonesia. Poster No.198 ISPPD 11th. April 2018, Melbourne

Perawatan RS karena Pneumonia Pneumokokus pada Balita
IPD refers to PE, P-CAP, meningitis, bacteremia, peritonitis, arthritis, cellulitis and other.
CAP=community-acquired pneumonia; CI=confidence interval; PE=pneumococcal empyema; P-CAP= pneumococcal community-acquired pneumonia; P-PD=pneumococcal pulmonary disease
(P-CAP+PE).
López EL, et al. J Pediatric Infect Dis Soc. 2017; doi: 10.1093/jpids/piw089.
34
Perawatan RS Pneumonia Pneumokokus menurun ~72% setelah
program imunisasi PCV. Perawatan RS karena Pneumonia
Pneumokokus + Empiema menurun ~64% pada periode yang sama
Hospitalization
rates
(per
10,000
admissions)
0,
4,
8,
12,
16,
20,
Pre-PCV Post-PCV
11.8
(95% CI 8.4–15.9)
3.3
(95% CI 1.6–5.9)
Perawatan RS Pneumonia Pneumokokus*
Perawatan RS karena
Pneumonia Pneumokokus+Empiema†
0,
4,
8,
12,
16,
Pre-PCV Post-PCV
3.9
(95% CI 1.6–6.2)
10.9
(95% CI 7.2–14.5)
The pre-PCV period was 2009–2011; the post-PCV period was 2012–2013.
*P-CAP was pneumococcal CAP confirmed by positive blood culture.
†P-PD was pneumococcal pulmonary disease defined as P-CAP plus pneumococcal empyema.
~72%
reduction
~64%
reduction
Argentina, PCV 2+1

Efek Pneumococcal Conjugate Vaccine
• Penurunan penyakit pneumokok invasif
• Penurunan Nasal Carriage
• Imunitas HERD pada populasi yang tidak
diimunisasi
• Penurunan insidens resistensi antibiotik

Vaksin Pneumokokus, Bagaimana Bila Anak
Baru Datang Di Usia > 1 Tahun ?
Tidak Ada Kata Terlambat
Berikan Imunisasi PCV semasa Balita
Usia Dosis
3 kali, 4–8 minggu jarak antar dosis, dosis ketiga setelah usia 1
tahun, atau minimal 2 bulan setelah dosis kedua
7–11
Bulan
2 kali, minimal diberikan 2 bulan setelah dosis pertama
1 kali, dapat diberikan hingga usia 5 tahun
12–23
Bulan
>24
Bulan
1. http://www.idai.or.id/artikel/klinik/imunisasi/jadwal-imunisasi-2017 2. Latest BPOM Approved PCV13 Local Product Document. 2017

Deteksi dini Pneumonia (WHO)
HITUNG FREKUENSI NAPAS !!
Napas cepat (tachypnea)
Batasan frek napas
Umur frekuensi nafas
< 2 bulan 60
2 - 12 bulan 50
1 - 5 tahun 40
Chest Indrawing
(tarikan dinding dada ke dalam)

Obati !!!!!!
• Setiap kader kesehatan dan petugas kesehatan mampu
melakukan Manajemen Terpadu Balita Sakit (MTBS).
• Diagnosis dini dan tepat oleh dokter.
• Pemberian antibiotik pada anak dengan gejala pneumonia,
seperti amoksisilin , mencegah kematian hanya 5000 rupiah.
• Pemberian oksigen dan rujuk segera ke fasilitas kesehatan bila
gejala pneumonia berat.
• Kesadaran masyarakat akan pneumonia.

KESIMPULAN
• Pneumonia merupakan penyebab kematian utama
balita di dunia termasuk di Indonesia
• Vaksinasi terkait pneumonia berperan menurunkan
angka kematian balita dan beban penyakit pneumonia
dan beban resistensi antibiotik
• Orang tua, kader, mahasiswa, pemuka masyarakat dan
petugas / tenaga medis berperan dalam pencegahan
dan penanggulangan pneumonia
• Pencegahan, deteksi dini dan pengobatan yang tepat
dapat menurunkan kematian akibat pneumonia

3.Pencegahan Pneumonia.pdf

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