【Name】Agung Budi Sutiono【Organization】 (at the time of the grant):
The University Electro Communications, Graduate School of Information Systems【Title of Research】
Epidemic analysis typhoid fever with complications on disaster affected area in Indonesia【Purpose of Research】
A disaster is a situation that impacts negatively on society and the environment andis caused by natural or man-made hazards. Over the last 4 years, natural disasters inIndonesia have become almost inevitable. On December 26, 2004, an earthquake
measuring 9.0 on the Richter scale occurring 150 km off the coast of Sumatra-Indonesia in
the Indian Ocean triggered a widespread tsunami that hit Aceh 45 minutes later anddevastated an 800 km coastal strip. Roughly 130,000 people died, and a further 37,000
went missing presumed dead. Two years later, on May 27, 2006, in the Indian ocean,around 25 km south-southwest of Yogyakarta city, on the southern side of Java island,
earthquakes struck again, affecting 36,299 people, with 5,782 fatalities and 135,000 homes
damaged (CNN, 2006).
Epidemics and infectious diseases are further problems in disaster affected areas.
Typhoid fever is one of the epidemic infectious diseases, which occurs in humans due tosystemic infections; mainly caused by Salmonella typhi bacteria and which may cause
serious complications in disaster affected areas. It is known as a water borne disease, which
is transferred to food from human excreta via hands. For internally displaced persons (IDPs),
it is frequently difficult to acquire clean water for cooking or their own daily activities. This
problem would be exacerbated by unhealthy human behavior in society.
There are many factors that influence typhoid fever as mentioned in previous
studies in Indonesia. In 1997, Velema and colleagues located high risk groups and behavior
in Ujung Pandang South Sulawesi and concluded that education and hand washing wereneeded to avoid typhoid fever. Gasem et al 2001 identified the risk factors in Semarang thatwere related to poor food hygiene and housing. The variables used were educational level,
hand washing, eating outdoors and jobs. Gasem found that typhoid was usually associatedwith poor housing, inadequate food and personal hygiene. Vollard et al, in 2004, presented
the fact that the transmission of typhoid fever was mainly within the household with thevariables related family income, hand washing, clean water and sharing food.
Research purpose
The analysis, surveillance and control of social factors in infectious disease are theimportant functions in public health. Whether the type of disaster can influence and thestrategy to prevent typhoid fever complication in disaster affected area have not been
determined. In particular, such a strategy of avoiding typhoid complications in disaster
affected area needs to be considered.
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【Content/Methodology of Research】
Data collection and inclusion criteria
As a courtesy, ethics and permission to do the study was also obtained from the Director of
Zainoel Abidin hospital in Banda Aceh, Sardjito Hospital and Bantul health office Yogyakarta,
and Hasan Sadikin hospital Bandung. Inclusion criteria were typhoid fever patients andpositive Salmonella typhi by culture or laboratory widal test in hospital. Widal test is a tube
dilution test which measure human antibodies against the Salmonella typhi antigen. Blood
and/or bone marrow test was not done in both disaster affected area due to lack of facilities.
Nevertheless the widal test was still useful while interpreted with care. Patient’s data wasconfirmed and noted from medical record, subsequently survey was conducted to see
situation and to interview respondents. Inform consent was obtained from the respondent
concerning about this study. Respondent would be excluded if they did not agree to join on
this study. Data were stored anonymously and confidentially. During surveillance, open
ended questionnaire had been made to guide interviewers and respondents in order tofocus on the subject. Volunteers were recruited from staff or medical student at Syiah Kuala
University in Banda Aceh, Gajah Mada University in Yogyakarta, and Padjadjaran University
in Bandung to assist data collection and interview. Short training and explanation were given
before surveillance and interviewing respondents. Interview was done directly at thepatient’s home. In case of patients was uncooperative like children, question was aimed tothe mother or family member. Socio-cultural and customs must be precedence due to ineach province of Indonesia has difference kind of customs and culture. Demographic data
was requested to the local office government and permission from the person in charge wasobtained as long as data from central bureau of statistics website was not sufficient.
Interview
This interview was conducted due to lack of disaster situation information in the
medical record. We performed open ended questionnaire with informal nature of interview
that allows for the empathic relationships between the interviewer and patients which wasappreciated. All participants were response positively after giving informed consent as animportant point to enable patients to be fully aware of what they were participating in. We
collaborated with the local medical students because they were already familiar with thelocal customs, culture and language in each districts. It was necessary since we had tocommunicate to the patients in the local language, respecting their customs and culture as
well. Although we have national language but not all respondents could speak Indonesianlanguage as well and it would be easier for them to understand the subject of questions
while using their local language. The people with lower educational level were purely
speaking in the Javanese and Aceh language. The response of the patients was attemptedin the complete explanation, in order to obtain the real description of disease and disastersituation.
Questionnaire
Open ended questionnaires were used to guide the interviewers to explore
patient’s experience retrospectively. The format examples of the interview were as follow:•“What was the doctor suggested to you after recovery?”•“Why did you decide to recheck to the health facilities as the doctor suggested?”•“How did you obtain the drugs and drink it properly?”2•“How did you get the clean water and check it?”•
“Why do you think, you have to wash your hands?”•“How did you contact with other typhoid patients?”•“What kind of complications did you have? (Confirmed with the medical record)”.
An open ended questionnaire is designed to encourage a full, meaningful answer using thepatient’s own experiences. It is tend to be more objective and less leading than closed
ended questionnaire which encourages a short or single word answer.
Discriminant analysis
The typhoid variables from questionnaires were entered to the Microsoft Excel 2003 andSPSS 16.0 was applied for discriminant analysis. The purpose of discriminant analysis is todefine the predictors of typhoid complications selected variables in each district. If P value ofless than 0.05 then variables were considered significant. Wilks’ lambda was obtained toconsider the power to differentiate districts. The smaller Wilks' lambda for an independent
variable, the more that variable contributes to the discriminant function. Wilks’ lambda varies
from 0 to 1, with 0 meaning group means differ (thus the more the variable differentiates thegroups), and 1 meaning all group means are the same.
【Conclusion/Observation】
The complications of typhoid fever were founded in three districts. Many authors
reported that the incidence of complications was common in typhoid fever as long as thetreatment was not properly reached. Those complications would become burdens for
hospitals while the situation was getting worse in disaster. The availability of diagnosis
testing in disaster affected area is the other problem beside the difficulties of making
diagnosis since it has the same symptoms like the other fever disease. In this case, thepreparation of quick diagnostic device for typhoid fever is able to be considered forscreening if such a number of cases had been reported. Gasem 2002 reported that simple
rapid dipstick assay can be useful for quick diagnosis on typhoid fever in disaster Indonesia.

3Table 1.Characteristic of typhoid fever patients in tsunami (Aceh),
earthquakes (Yogyakarta) and normal situation (Bandung)
Variables

Classification

Age [years]

Mean ± SD
Range
Male
FemalePrimary
Secondary

Gender
Education

Recheck
Go to recheck
Drug availability
Clean water
Water checking
Hand washing
Contact with other typhoid
Complications

Tsunami(Aceh )
n=42 [%]
36.1 ± 15.4
11-65
25[59.5]
17[40.5]
13[31.0]29[69.0]38[90.5]30[71.4]
28[66.7]
34[81.0]10[23.8]
38[90.5]
19[45.2]
5[11.9]Earthquake(Yogyakarta)
n=39 [%]
35.5 ± 14.5
13-80
20[56.4]
19[43.6]
22[56.4]
17[43.6]
36[92.3]
30[76.9]28[71.8]
32[82.1]
9[23.1]35[89.7]
17[43.6]
8[20.5]

Normal situation(Bandung)
n=70 [%]
19.3 ± 13.7
7-61
28[40.0]42[60.0]47[67.1]
23[32.9]64[91.4]
51[72.9]50[71.4]
58[82.9]
15[21.4]
64[91.4]
36[51.4]
13[18.6]

In the aftermath of tsunami in Aceh, there were serious concerns regarding theclean water supplies and drugs availability. Consequently providing clean water supply,
drugs distribution properly is the priority in tsunami. The diminishing direct contact withtyphoid patients among internally displaced persons (IDPs) on the earthquakes in
Yogyakarta is the way to avoid the typhoid transmission. Meanwhile in Bandung, Personally,a good hand washing is the line of defense against the typhoid infection and supporting
drugs freely for the patients are need to be considered.
Table 2.Discriminant analysis with grouping variable complication and selected variable by district
TsunamiEarthquake
Normal situation(Aceh)(Yogyakarta)(Bandung)
Variables
Wilks'
Wilks'
Wilks'
Sig.
Sig.
Sig.
LambdaLambdaLambda
Age
0.999
0.843
0.960
0.220
1.000
0.875
Gender
0.976
0.332
0.987
0.490
0.992
0.459
Education
0.848
0.011*
0.899 0.048*
0.888
0.005*
Recheck
0.983
0.408
0.992
0.579
0.986
0.338
Go to recheck
0.995
0.661
0.970
0.290
0.985
0.316
Drug availability
0.730
0.000*
0.969
0.280
0.929
0.025*
Clean water
0.426 0.000* 0.991
0.572
0.994
0.536
Water checking
0.958
0.192
0.984
0.439
0.995
0.563
Hand washing
0.983
0.408
0.999
0.820
0.857 0.001*
Contact with other typhoid
0.999
0.808
0.666 0.000*
0.997
0.679
Significant level at P<0.05

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