Middle East Respiratory Syndrome (MERS) adalah salah satu penyakit new emergence dengan potensi pandemi. Globalisasi menjadi salah satu bahasan menarik yang melingkupi penelitian dan pengetahuan tentang MERS dan dampaknya bagi populasi manusia. Presentasi ini dibawakan di depan mahasiswa Akademi Keperawatan Panti Rapih, Sabtu, 7 Juni 2014, sebagai pengantar kegiatan praktek klinik.

1. Middle East Respiratory Syndrome &
Tantangan Global Health
Robertus Arian Datusanantyo
http://media.npr.org/

2. Pengantar
http://followtheoutbreak.files.wordpress.com/
I

3. Beberapa Outbreak
Tahun Nama Penyebab
1968 Hong Kong Flu
Virus Influenza A
subtipe H2N2
2003
Avian Influenza (AI) Virus Influenza A
subtipe H5N1
2003
Severe Acute Respiratory
Syndrome (SARS)
SARS Coronavirus /
SARS-CoV
2009
Swine Flu / Flu Babi Virus Influenza A
subtipe H1N1
2012
Middle East Respiratory
Syndrome (MERS)
MERS Coronavirus /
MERS-CoV

4. (Kasus Pertama di Inggris, seperti dilaporkan Pebody et al 2012)

5. (Dugaan penularan manusia ke manusia seperti yang dilaporkan The Health Protection
Agency (HPA) UK Novel Coronavirus Investigation team 2013)

6. (Kasus pertama dan kedua dengan dugaan penularan manusia ke manusia di Perancis
seperti dilaporkan Mailles et al 2013)

7. (Kasus Pertama di Jerman, seperti dilaporkan Buchholz et al 2013)

8. Keterlibatan Global
¨ Sejak April 2012, ada 536 kasus konfirmasi
dengan 145 kematian (case fatality proportion
27,05%).
¨ Timur Tengah: Yordania, Kuwait, Oman,
Qatar, Arab Saudi, Uni Emirat Arab, Yaman.
¨ Afrika: Mesir dan Tunisia.
¨ Eropa: Perancis, Jerman, Yunani, Italia, dan
Inggris.
¨ Lainnya: Malaysia Filipina, Amerika Serikat
¨ 65,6% laki-laki, median usia: 49 tahun.
World Health Organization, 9 Mei 2014

9. Fakta-fakta Klinis
http://www.shevet.org/
II

10. Phylogenetic relationships among members of the subfamily Coronavirinae and taxonomic
position of MERS-CoV.
de Groot R J et al. J. Virol. 2013;87:7790-7792

11. People Under Investigation (PUI)
A. Fever(≥38°C) and pneumonia or acute respiratory distress
syndrome (based on clinical or radiological evidence) AND
EITHER:
A. a history of travel from countries in or near the Arabian
Peninsula within 14 days before symptom onset, OR
close contact with a symptomatic traveler who developed fever
and acute respiratory illness (not necessarily pneumonia)
within 14 days after traveling from countries in or near the
Arabian Peninsula OR
B. a member of a cluster of patients with severe acute respiratory
illness (e.g. fever and pneumonia requiring hospitalization) of
unknown etiology in which MERS-CoV is being evaluated, in
consultation with state and local health departments.
OR
B. Close contact with a confirmed or probable case of MERS
while the case was ill AND
A. fever (>100°F) or symptoms of respiratory illness within 14
days following the close contact.
(CDC 2014)

12. Confirmed / Probable Case
¨ A confirmed case is a person with laboratory
confirmation of MERS-CoV infection.
¨ A probable case is a PUI with absent or
inconclusive laboratory results for MERS-CoV
infection who is a close contact of a laboratory-
confirmed MERS-CoV case.
http://watchdog.wpengine.netdna-cdn.com/
(CDC 2014)

13. Pencegahan
¨ Cuci tangan dengan sabun dan air
selama 20 detik. Dewasa / anak. Atau
gunakan alcohol-based hand
sanitizer.
¨ Tutup hidung dan mulut dengan tisu
saat batuk / bersin, lalu buang tisu ke
tempat sampah.
¨ Hindari menyentuh mata, hidung, dan
mulut dengan tangan kotor.
¨ Hindari kontak personal: ciuman,
berbagi alat makan / gelas, dengan
orang sakit.
¨ Bersihkan & desinfeksi berkala
permukaan barang yang sering
disentuh, misal gagang pintu dan
mainan.
Koleksi Pribadi
(CDC 2014)

14. Gambaran Klinis
¨ Gejala umum: demam, batuk, sesak
nafas.
¨ Spektrum lebar: dari asimtomatik
sampai multi organ failure dan
kematian.
¨ Case fatality proportion 28-30%
¨ Saat MRS: demam, menggigil, sakit
kepala, batuk kering, sesak nafas, dan
nyeri otot.
¨ Gejala lain: nyeri tenggorok, pilek,
mual, muntah, dizziness, dahak, diare,
dan nyeri perut.
¨ Perlu ICU: ISPA dengan progresi cepat
ke pneumonia dalam seminggu.
http://ak4.picdn.net/
(CDC 2014)

15. Perjalanan Alamiah Penyakit
¨ Masa inkubasi transmisi antar manusia: 5 (2-13) hari.
¨ Pada MERS-CoV: onset sampai MRS 4 hari.
¨ Pada pasien kritis: onset sampai ICU 5 hari, median
onset sampai kematian 12 hari.
¨ Radiografis: peningkatan densitas atau opasitas, infiltrat
interstisial, konsolidasi, efusi pleura.
¨ Perburukan: gagal nafas akut, ARDS, hipoksemia
berulang, komplikasi ekstrapulmoner (AKI, hipotensi,
hepatitis, syok septik).
¨ Laboratoris: leukopenia, limfopenia, thrombositopenia,
dan kenaikan laktat dehidrogenase.
(CDC 2014)

16. A) Chest radiograph of a 61-year-old man, showing bilateral fine reticulonodular air-space opacities, increased vascular
markings, and cardiomegaly. (B) Chest radiograph of an 83-year-old man, showing right lung consolidation, right basal
pleural thickening, and reticulonodular air-space opacities; rib fractures on the right are old. (C) Chest radiograph of a 56-
year-old man, showing extensive bilateral extensive diffuse and focal alveolar space opacities, with opacification of the left
lower lobe. (D) Chest radiograph of a 67-year-old man, showing extensive bilateral disease, with diffuse alveolar space
densities, opacification, reticulonodular opacities, and bronchial wall thickening. (E) Chest radiograph of a 49-year-old
man, showing extensive bilateral mid and lower zone disease, with diffuse reticulonodular alveolar space opacities. A
thoracic CT scan in the same patient (F) shows extensive bilateral opacities and ground-glass reticulonodular shadowing
and bronchiolar wall thickening. (Assiri et al 2013)

17. Map of the Kingdom of Saudi Arabia showing the 2 study hospitals, the number of suspected and confirmed MERS-CoV
infections in patients, and the number of HCWs screened and cases confirmed in HCWs. ICU 1 is located in Al-Ahsa and
ICU 2 and ICU 3 in Riyadh. HCW = health care worker; ICU = intensive care unit; KAH = King Abdulaziz Hospital; KAMC =
King Abdulaziz Medical City; MERS-CoV = Middle East respiratory syndrome coronavirus; UAE = United Arab Emirates.
Arabi et al 2014; Copyright © American College of Physicians. All rights reserved.

18. Study flow diagram.
HCW = health care worker; ICU = intensive care unit; MERS-CoV = Middle East respiratory syndrome coronavirus.
* Cases described in this report.
Arabi et al 2014; Copyright © American College of Physicians. All rights reserved.

19. Arabi et al 2014; Copyright © American College of Physicians. All rights reserved.

20. Arabi et al 2014; Copyright © American College of Physicians. All rights reserved.

21. Kesiapan Rumah Sakit
http://hill-kleerup.org/
III

22. Transmission Map of Outbreak of MERS-CoV Infection.
Assiri A et al. N Engl J Med 2013;369:407-416.

23. Penularan di Rumah Sakit
¨ Di Jeddah, >60% dari 128
kasus kemungkinan
mendapat infeksi di rumah
sakit (WHO, 2014).
¨ … jelas dari klaster yang
berhubungan dengan
pelayanan kesehatan,
transmisi manusia ke
manusia terjadi akibat
paparan tanpa proteksi…
(Arabi et al 2014).
http://images.thenews.com.pk

24. Penempatan Pasien
¨ Airborne Infection
Isolation Room.
¨ Masker, single room
dengan pintu tertutup.
¨ Filtrasi High-efficiency
particulate air (HEPA)
¨ Batasi transportasi
¨ Batasi kontak, gunakan
APD
http://www.mskcc.org/
(CDC 2014)

25. Kesiapan Petugas
¨ Alat perlindungan diri
¤ Gaun
¤ Masker N95
¤ Kaca mata
¤ Sarung tangan
¨ Hand hygiene
¤ Cara cuci tangan
¤ 5 moments in hand hygiene
¨ Edukasi keluarga /
pengunjung
¨ Pembuangan limbah
¨ Penanganan linen
http://cdn.65emall.com/
(CDC 2014)

26. Global Health
http://hill-kleerup.org/http://s.imwx.com/
IV

27. Beberapa Outbreak
Tahun Nama Penyebab
1968 Hong Kong Flu
Virus Influenza A
subtipe H2N2
2003 Avian Influenza (AI)
Virus Influenza A
subtipe H5N1
2003
Severe Acute Respiratory
Syndrome (SARS)
SARS Coronavirus /
SARS-CoV
2009 Swine Flu / Flu Babi
Virus Influenza A
subtipe H1N1
2012
Middle East Respiratory
Syndrome (MERS)
MERS Coronavirus /
MERS-CoV

28. Apa kesamaan dari kelima
contoh outbreak pada slide
sebelumnya?
http://www.mynamesnotmommy.com/

29. Beberapa Ciri Serupa
¨ Penyakit baru, progresif, fatality rate tinggi.
¨ Menyebar cepat
¨ Melibatkan hewan (unggas, babi, kelelawar,
unta, dll)
¨ Dugaan kuat transmisi dari manusia ke
manusia
¨ Mempengaruhi pengambilan keputusan politis
¨ Berhubungan dengan kegiatan ekonomi global

30. Global Health
¨ An area for study, research, and practice that
places a priority on improving health and
achieving equity in health for all people
worldwide.
¨ Emphasizes transnational health issues,
determinants, and solutions
¨ Involves many disciplines within and beyond the
health sciences and promotes interdisciplinary
collaboration
¨ A synthesis of population-based prevention with
individual-level clinical care
(Koplan et al 2014)

31. Global Health
Geographical reach Focuses on issues that directly or
indirectly affect health but that can
transcend national boundaries
Level of cooperation Development and implementation of
solutions often requires global
cooperation
Individuals or populations Embraces both prevention in populations
and clinical care of individuals
Access to health Health equity among nations and for all
people is a major objective
Range of disciplines Highly interdisciplinary and
multidisciplinary within and beyond
health sciences
(Koplan et al 2014)

32. International Health
(Koplan et al 2014)
Geographical reach Focuses on health issues of countries
other than one’s own, especially those of
low-income and middle-income
Level of cooperation Development and implementation of
solutions usually requires binational
cooperation
Individuals or populations Embraces both prevention in
populations and clinical care of
individuals
Access to health Seeks to help people of other nations
Range of disciplines Embraces a few disciplines but has not
emphasized multidisciplinary

33. Public Health
(Koplan et al 2014)
Geographical reach Focuses on issues that affect the health of
the population of a particular community
or country
Level of cooperation Development and implementation of
solutions does not usually require global
cooperation
Individuals or populations Mainly focused on prevention
programmes for populations
Access to health Health equity within a nation or
community is a major objective
Range of disciplines Encourages multidisciplinary approaches,
particularly within health sciences and
with social sciences

34. Global Health vs Globalisasi
¨ Penyebaran risiko kesehatan / penyakit di
dunia sering berhubungan dengan
perdagangan atau usaha penguasaan.
¨ Peningkatan kecepatan komunikasi dan
perjalanan, juga saling ketergantungan
ekonomi antar bangsa, mengakibatkan
timbulnya tingkat dan kecepatan saling
keterhubungan baru yang disebut
globalisasi.
¨ Global health menggunakan sumber
daya, pengetahuan, dan pengalaman
beragam bangsa untuk menjawab
tantangan kesehatan di seluruh dunia.
(Koplan et al 2014) http://wardheernews.com

35. Infeksi: Faktor Berpengaruh
The Microbial Agent The Human Host The Human Environment
Genetic adaptation and change Human susceptibility to
infection
Climate and weather
Polymicrobial diseases Human demographics and
behavior
Changing ecosystems
International trade and travel Economic development and
land use
Intent to harm (bioterrorism) Technology and industry
Occupational exposures Poverty and social inequality
Inappropriate use of antibiotics Lack of public health services
Animal populations
War and famine
Lack of political will
(Morens & Fauci 2013)

36. http://www.dubaiairport.com/

37. http://cosmone.com/

38. http://images.dailystar-uk.co.uk/

40. RefleksiV
http://3.bp.blogspot.com/

41. Ringkasan
¨ MERS adalah penyakit infeksi baru yang
berpotensi mengganggu global health.
¨ Sedikit yang telah diketahui namun banyak hal
umum yang bisa diaplikasi.
¨ Sampai saat ini, Indonesia belum termasuk dalam
daftar negara terlibat MERS.
¨ Indonesia, walau bagaimana, berpotensi BESAR
terlibat dalam penularan MERS.
¨ Kita sebagai tenaga kesehatan tidak mungkin
menghindari isu-isu global health, terutama soal
infeksi (new-emergence maupun re-emergence).

42. Refleksi
¨ Apa yang telah saya pelajari dari pemaparan
ini?
¨ Pengetahuan apa yang saya sudah tahu, dan
pengetahuan baru mana yang saya dapat?
¨ Apakah pengetahuan baru ini mempunyai
kontribusi pada diri saya?
¨ Bagaimana saya dapat berkontribusi pada
masyarakat lewat pengetahuan ini?
¨ Pertanyaan apa yang saya harus cari
jawabannya terkait pengetahuan baru ini?

43. Quiz - Berhadiah
¨ Berdasarkan pemaparan tadi dan refleksi yang anda
lakukan, buatlah tulisan sepanjang kurang dari 8
paragraf mengenai refleksi anda!
¨ Anda dapat menulis apa saja, dari sudut pandang
mana saja. Semakin unik, semakin menarik.
¨ Quiz ini sukarela, tidak wajib.
¨ Attach tulisan via email ke arian9677@gmail.com
sebelum Rabu, 11 Juni 2014 tengah malam. Tuliskan
pada subjek: “Refleksi MERS”.
¨ Tersedia hadiah menarik bagi dua tulisan terbaik.
¨ Tidak ada sponsor pada quiz ini.

44. Referensi
http://librosschmibros.files.wordpress.com/
VI

45. Referensi (1)
¨ Arabi YM; Arifi AA; Balkhy HH; Najm H; Aldawood AS; Ghabashi A; Hawa H; Alothman A;
Khaldi A; Raiy BA. Clinical Course and Outcomes of Critically Ill Patients With Middle East
Respiratory Syndrome Coronavirus Infection. Ann Intern Med. 2014;160:389-397. Available
online: http://annals.org/article.aspx?articleid=1817260
¨ Assiri A, Al-Tawfiq JA, Al-Rabeeah AA, Al-Rabiah FA, Al-Hajjar S, Al-Barrak A, Flemban H, Al-
Nassir WN, Balkhy HH, Al-Hakeem RF, Makhdoom HQ, Zumla AI, Memish ZA. Epidemiological,
demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome
coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect Dis 2013; 13: 752–61.
Available online: http://dx.doi.org/10.1016/S1473-3099(13)70204-4
¨ Assiri A, McGeer A, Perl TM, Price CS, Al Rabeeah AA, Cummings DAT, Alabdullatif ZN, Assad
M, Almulhim A, Makhdoom H, Madani H, Alhakeem R, Al-Tawfiq JA, Cotten M, Watson SJ,
Kellam P, Zumla AI, Memish ZA. Hospital Outbreak of Middle East Respiratory Syndrome
Coronavirus. N Engl J Med 2013;369:407-16. DOI: 10.1056/NEJMoa1306742. Available online:
http://www.nejm.org/doi/full/10.1056/NEJMoa1306742
¨ Buchholz U, Müller MA, Nitsche A, Sanewski A, Wevering N, Bauer-Balci T, Bonin F, Drosten C,
Schweiger B, Wolff T, Muth D, Meyer B, Buda S, Krause G, Schaade L, Haas W. Contact
investigation of a case of human novel coronavirus infection treated in a German hospital,
October-November 2012. Euro Surveill. 2013;18(8):pii=20406. Available online:
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20406
Berikutnya…

46. Referensi (2)
¨ Centers for Disease Control and Prevention. Interim Infection Prevention and Control
Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome
Coronavirus (MERS-CoV). Available Online:
http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html
¨ Centers for Disease Control and Prevention. Middle East Respiratory Syndrome (MERS) Case
Definitions. Available Online: http://www.cdc.gov/coronavirus/mers/case-def.html
¨ Centers for Disease Control and Prevention. Middle East Respiratory Syndrome (MERS) Clinical
Features. Available Online: http://www.cdc.gov/coronavirus/mers/clinical-features.html
¨ Centers for Disease Control and Prevention. Middle East Respiratory Syndrome (MERS)
Prevention and Treatment. Available Online:
http://www.cdc.gov/coronavirus/MERS/about/prevention.html
¨ Centers for Disease Control and Prevention. Middle East Respiratory Syndrome (MERS)
Symptoms and Complications. Available Online:
http://www.cdc.gov/coronavirus/MERS/about/symptoms.html
¨ Groot RJ, Baker SC, Baric RS, Brown CS, Drosten C, Enjuanes L, Fouchier RAM, Galiano M,
Gorbalenya AE, Memish ZA, Perlman S, Poon LLM, Snijder EJ, Stephens GM, Woo PCY, Zaki
AM, Zambon M, Ziebuhr J. Middle East Respiratory Syndrome Coronavirus (MERS-CoV):
Announcement of the Coronavirus Study Group. J. Virol. 2013, 87(14):7790. DOI: 10.1128/JVI.
01244-13. Available online: http://jvi.asm.org/content/87/14/7790.full
Berikutnya…

47. Referensi (3)
¨ Koplan, JP, Bond, TC, Merson, MH, Reddy, KS, Rodriguez, MH, Sewankambo, NK, Wasserheit
JN. Towards a common definition of global health. Lancet 2009; 373: 1993–95. DOI:10.1016/
S0140-6736(09)60332-9. Available Online:
http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673609603329.pdf?
id=aaaThPOBq3qThfUBjxWzu
¨ Mailles A, Blanckaert K, Chaud P, van der Werf S, Lina B, Caro V, Campese C, Guéry B, Prouvost
H, Lemaire X, Paty MC, Haeghebaert S, Antoine D, Ettahar N,
Noel H, Behillil S, Hendricx S, Manuguerra JC, Enouf V, La Ruche G, Semaille C, Coignard B,
Lévy-Bruhl D, Weber F, Saura C, Che D, The investigation team. First cases of Middle East
Respiratory Syndrome Coronavirus (MERS-CoV) infections in France, investigations and
implications for the prevention of human-to-human transmission, France, May 2013. Euro
Surveill. 2013;18(24):pii=20502. Available online:
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20502
¨ Morens DM, Fauci AS. Emerging Infectious Diseases: Threats to Human Health and Global
Stability. PLoS Pathog 2013:9(7): e1003467. DOI:10.1371/journal.ppat.1003467. Available
Online: http://www.plospathogens.org/article/info%3Adoi%2F10.1371%2Fjournal.ppat.1003467
Berikutnya…

48. Referensi (4)
¨ Pebody RG, Chand MA, Thomas HL, Green HK, Boddington NL, Carvalho C, Brown CS,
Anderson SR, Rooney C, Crawley-Boevey E, Irwin DJ, Aarons E, Tong C, Newsholme W, Price N,
Langrish C, Tucker D, Zhao H, Phin N, Crofts J, Bermingham A, Gilgunn-Jones E, Brown KE,
Evans B, Catchpole M, Watson JM. The United Kingdom public health response to an imported
laboratory confirmed case of a novel coronavirus in September 2012. Euro Surveill.
2012;17(40):pii=20292. Available online:
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20292
¨ The Health Protection Agency (HPA) UK Novel Coronavirus Investigation team. Evidence of
person-to-person transmission within a family cluster of novel coronavirus infections, United
Kingdom, February 2013 . Euro Surveill. 2013;18(11):pii=20427. Available online:
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20427
¨ World Health Organization. Middle East respiratory syndrome coronavirus (MERS‐CoV)
summary and literature update–as of 9 May 2014. Available Online:
http://www.who.int/csr/disease/coronavirus_infections/
MERS_CoV_Update_09_May_2014.pdf?ua=1

49. Terima kasih atas perhatiannya!
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robertusarian/mers-dan-global-health.
Koleksi Pribadi