d' Padang Terap Team reporting...

Day 8(05/08/08)

Today we had briefing on Occupational and Environmental Health unit or KPAS (Kesihatan Pekerjaan dan Alam Sekitar) by Mr. Muhammad Fadzil(PPKP). We had short briefing on how the unit is works and as a field work, we followed him for an auditing work in a “Klinik Desa” nearby.

On his briefing, he explained to us that this unit only responsible for the occupational health of individuals working under the health ministry. The unit is responsible in providing all the safety equipments needed by other units and also health care providers. For example they provide safety vest for JM’s in “Klinik Desa” used when they go for house visit.

Then he explained to us about the forms that used to record the cases in health care units. The diseases are noise induced hearing loss, skin diseases, poisoning and lung diseases. Accident and sharps injury also will be notified and investigated.

Besides that, KPAS also responsible in making sure that certain group of health care providers get their Hepatis B vaccination. They are doctors, pharmacists, nurses and laboratory workers. Everyone who falls into this category will require having their vaccination and a card will be given to them stating the date of injection, anti-HBs test and HBsAg test result for further reference.

End of the session, he explained to us about the auditing process required to access the safety of workplace and also the safety precautions taken by the workers. This requires us to fill up two forms and there will be a calculation to get their demerit point. The demerit point will be reference when they should have the next auditing. If the point is more than 75%, the next auditing will 3years once, followed by 2 years once if the point is 50-75% and less than 50% indicates auditing of 6 months once. The form that used is OHU/Audit H&S-1 and Sheet 1.

Then we visited “Klinik Desa” Nako Nambua for auditing. Upon reaching and greeted by the JM, we start our auditing with the help of PPKP and his assistant. It takes about 1 hour to finish our auditing. Our attachment with KPAS unit is over with the field work in “Klinik Desa”.

In evening, we joined Vector unit for fogging activity at Kg.Hulu. Before heading to the village, we’re given short briefing on Vector unit and how the fogging is is done.

d" Padang Terap Team Reporting....

Day 4-holiday

Day 5 (1/8/08)

As normal we reached the office at 8am and we scheduled to have briefing about the non-communicable disease and also the about the enforcement unit.

The officer, Mr.Zuraidi greet us with warm welcome to the meeting with him. He is responsible for two units and he is the only PPKP for that two units which comes under the PPKPK, Mr.Ali.

The two unit that under him is non-communicable disease unit and also enforcement unit. First of all, he started with the details of enforcement unit which responsible in charging those people who caught for health related offense.

He explained to us the flow of the process involved from the point of someone is get caught until the point his/her case goes to the court. He used the example of smoking in area which labeled as non-smoking area.

Unfortunately we can't join him on the enforcement activity even we're just 4 in number because he wanted to avoid the consequences that we will be facing if someone is get caught. We are quite disappointed for not able to join him on his activity.

Before leaving, he briefly told us about the non-communicable diseases and will be telling us in detail next week.

That's all for week 1 of DHO posting...

Padang Terap Team Reporting....

hi! everyone,
Sorry for late update of daily report of my group. It is due to some technical problem that cannot be avoided.

Day 3 report:

As normal we arrived at the health office at 8am awaiting for some field work. As scheduled, today we had be given briefing by Tuan Haji Yaakob regarding HIV/AIDS cases and tuberculosis cases managed.

He started his briefing with some statistic about the HIV/AIDS cases. There is 3 identified HIV -positive case in Padang Terap this year. And he is not able to reveal the total cases that already identified and being treated in Padang Terap District.

His briefing mainly focused on:

1. screening
2. diagnosis
3. what is the role of district health office when HIV/AIDS patient passed away.

Screening
-before marriage, it is compulsory for the Islam couples to get their HIV/AIDS screening done before they proceed with their marriage
-voluntary with details, whereby such person gives their full consent to get their blood tested for HIV/AIDS
-voluntary without name, gives full consent for report but there will be only identification number and the person just can call the office to know their result.

Diagnosis
According to Tn Haji Yaakob, the diagnosis of HIV/AIDS only confirmed after the person who is positive of screening test undergone two ELISA test and both shows positive.

After the confirmation of the diagnosis, the details of patient is will be inserted into CDCIS or E-NOTICE which will act as database for Health Ministry to monitor the cases with the help of DHO.

when the HIV/AIDS patient passed away..Close monitoring by the CDC unit
The patient will be wrapped into few layers of clothes and plastics before given to the their family. The patient will be cleaned with hypochloride solution then a layer of white cloth will be used followed by the plastic cover. Then will be wrapped again with the cloth. This procedure is mainly done in hospitals.

In case where the patient passed away in house and he/she not brought to hospital, the DHO will be providing the family with necessary things such as apron, mask and clothes.

Tuberculosis
Tuan Haji Yaakob explained very briefly about the procedures and the forms that used in process of treating tuberulosis and eradicating the contacts

There is 12 forms that used in case of Tubeculosis.

Form 10A1- case monitoring
Form 10A2- confirmation
form 10A3- investigation (hospital and field)
Form 10A4- record purpose

Form 10B1- hospital record
Form 10B2-hospital record summary

Form 10C1 and Form 10C2 - Contact form

Form 10E - defaulters

Form 10F - contuination of treatment

Form 10G- MDRT

Form 10J- Tuberculosis patient dies (*used only when the patient is still under medication)

He explained the procedures that to be followed when filling up the forms and also investigating the case.

In addition, he talled to us about DOTT (direct observation of tuberculosis treatment). It is normally done in chest clinic in hospital and the patient will be required to come there everyday to take anti-tuberculosis drugs under the observation of the nurses. It is normally done for at least 2 months and more for those who frequently defaulting the treatment course.

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Then Tuan Haji Yaakob brought us to Pondok Inabah 1 which located approximately 7km from district health office. Pondok Inabah 1 is the private centre to treat the drug abusers and it is recognised by the Anti-Dadah Kebangsaan (ADH).

There we briefed by the Tok Guru about the drug-free method to treat the drug abusers. It is mainly through holistic methods whereby the principle that they're using is follows Quran.

It was new experience to us whereby until now we thought that only government centers are providing such services.

more info to come as special report.

___________________________________________________________________

In afternoon we had pleasant visit by Dr.Sawrirajan.We explained to him the activities had been done so far and he gave some suggestions and instructions that should be done before the end of this posting.

We would like to thank him for his suggestions.

Then we had short discussion with Distric Health Officer, Dr.Latifah. She talked to us about the services that available in Health Clinics in this distric and also states more about the organization chart of the Padang Terap Distric Health Office.

We also would like to thank you her for the guidance and advise given

last day in kota setar

9.30- 11.30am
briefing by En.hassan(PPKPK) regarding occupational health

day 9 in kota setar district health office

today's activities\

8.30am-10.00am
speech by Mr.zaidi regarding water and sanitation(BAKAS,bekalan air dan kesihatan alam sekitar)
2.00pm-4.00pm
briefing on food quality and sampling by Mr.Mohd Fauzi. folowings are topics discussed:

1. role and function of Food Quality and Sampling unit
2. hoiw sampling is being done
3. rating of premises that sell food items(school canteens,restaurants,factories)

8th day of dho posting(kota setar)

as usual, the 1st session of briefing starts at 9am. Mr.Abdullah (PPKPK of vector unit) gave us talk on how to control an outbreak cause by vectors.in his talk,he stresed more on malaria and dengue outbreak.

ANSWERS TO DR. SAPNA'S QUESTIONS

THE QUESTIONS ARE:

1.Why is a second fogging done around a case of Dengue?
2.Why on the 7th day after the first fogging?
3.What is the insecticide used for fogging?What is the mechanism of action and the quantity in which it is used?
4.What are the different type of sprays used for fogging?

THE ANSWERS
(taken from Park's Textbook of Preventive and Social Medicine 17th edP544-548)

Question 1: It is done to kill any missed infected adult mosquitoes and newly grown adult mosquitoes from an infected pupa.

2. If an infected female mosquitoe so happen to lay eggs on the first fogging, the 'infected eggs' are protected from the fogging effect as the fog only effective in killing adult mosquitoes. The eggs will reach larva stage at day 5-7 and pupa stage at 6-7 days. A second fogging is done on day 7 to kill the Culicine (Culex, Aedes, and Mansonia) larvae through their siphon tube that is attached to its 8th segment of its body that is exposed to the air. But the main idea of fogging on 7th day is to kill the pupa. The pupa represents the resting stage in the life history of the mosquito.It has 2 small respiratory tubes (trumpets) project from the upper surface of the thorax, therefore the fod or mist sprayed on 7th day will effectively kill them as well.

3. The insecticide used in Malaysia for fogging normally is Resigen (S-bioallethrin, permethrin (25/75) and piperonyl butoxide). S-bioallethrin and Permethrin belongs to the family of synthetic chemicals called pyrethroids and functions as a neurotoxin, affecting neuron membranes by prolonging sodium channel activation. Piperonyl butoxide (PBO) is a pesticide synergist and also a potent cytochrome P450 inhibitor. It does not, by itself have pesticidal properties.
The quantity used in oil-based will be 1L of Permethrin (100mL of Resigen :1L of Diesel). *note, the fogging machine can fit 5.5L but the staffs prepare 5L of mixtures.

4. Other types of spray used are:
Residual insecticide (Malathion and fenitrothion) using ULV fogging.

KUALA MUDA, 31.7.08, (DAY 4): DAILY REPORT

KMDHO TEAM STARTED WITH HOPE BUT ENDED WITH DISAPPOINTMENT

As the title went, we really got disappointed when practical session for premise inspection and food sampling was cancelled as the person in charged could not make it to prepare us such activities. Besides that, it was Thursday and no food sampling will be taken as the Laboratory is off from friday till Sunday.

So, we continued with THEORY LECTURES again. We were briefed by PPKP Adam who is in charged of the Food Safety and Quality Control (FSQC).

PPKP Adam

The law used by this unit will be the Akta Makanan 1983 ( Food Act 1983), Peraturan makanan 1985 ( Food Regulations 1985), and Standard Peraturan Air Minuman berbungkus 1985 (Standard Regulation of Packed Water 1985). Practically, Peraturan-peraturan Hasil Tembakau 2004 (Tobacco Control Act 2004) comes under the Food Act and Food regulation.

He told us briefly about what the factory has to deal with DHO before setting up a food processing factory and surveillance done in school/food premise, factory, restaurant and static stalls.

When a new food related factory is established, the factory is required to apply license from State municipal. The municipal will then forward a letter to FSQC of KMDHO. FSQC unit will then conduct a food sampling on that premise besides assessing the cleanliness of the factory, machine, tools, and the staffs. Typhi IV card of the employees are assessed as well. Thyphi IV card is an identification card that is given when salmonella typhi vaccination is given to the food handler of the factory or food premise.

Then a random sampling of the food product will be done. The sample will be sent to Jabatan Kimia Penang (Penang Laboratory Dept.) and check the parameters such as chemical, physical and microbiological. Sample that require chemical and physical assessment must be sent to Laboratory by 3 days whereas sample must be sent within 24hours for microbiological parameters. Microbiological parameters include checking the presence of Salmonella spp, Staphylococcus Aureus, E. Coli, Coliform count and plate count.

After that, the label of the product will be assess according to Food regulation Act 1985 under Regulation 18 in which label with "Super, 100% Natural, King, Class 1, Brilliant, Quality Guaranteed, and High Quality are prohibited". Well, if someone were to ask me "How bout the brand Super Ring, Beras Super, and King ice cream?". I can only say, " sorry, I have no comment ladies and gentlemen".

When every assessment is passed, Health certificate will be issued by DHO of the state to the factory and the factory can now export to overseas as long as the requirements are met with the standard set by the importing country. For a better recognition, factory can apply Good Manufacturing Practice (GMP) and/or Hazard Analysis and Critical Control Point (HACCP). GMP is well recognised locally but not internationally. For HACCP, it is recognised both locally and internationally. If factory has HACCP recognition, food sampling is exempted. The municipal will then issue certificate to allow manufacturing in the last step of application process. For further information, JAKIM (the body that certify HALAL'ship') has no connection with DHO and they assess the food by themselves.

If the food sampling does not meet the requirement, the factory will not be closed but instead, the batch of the food produced will be disposed and a new batch of food is produced. Then the new sample is taken again until the batch of food produced meets the requirement.

For imported food such as the food brought in from Thailand, the product will be held at least 1-2 weeks for sampling. All the parameters are checked before the product are permitted to enter Malaysia. This topic is covered very briefly as we do not really have the facilities to appreciate the process. Hope the DHO team that is posted near to Thailand border will give us more coverage on this topic.

As for food surveillance, it will be done twice a year (especially in school canteen). If there is 1 outbreak of food poisoning, the surveillance will be done once every 4 months (3 times in a year). The premises are classified into Factory, Restaurant/Food Premise, School Canteen, Static Hawker, and Seasonal hawker (e.g. Lontong, festive cakes,and foods sold at a particular festive season). The process of surveillance and food sampling will be discussed in specific topic of day 4.

Then our activity is continued with lecture from KPAS unit at 2.30pm to 4.30pm by PPKP Tengku Baharudin. According to him, this unit is temporarily focusing on the health staffs only and will expand their scope on the other fields later in future. The main aspect that is taken cared by this unit is the Sharp Object Injury, Hepatitis B vaccination program, and Healthy Setting Program.

PPKP Tengku Baharudin

The law used in this unit will be Occupational Safety Health Act 1994 (OSHA ACT 1994). If someone is acting against this law, the guilty will be punished with a penalty of equal/less than RM50 000 or equal/less than 5 years of jail or both.

Any sharp injury must be notified within 24 hours to DHO office by phone and sent a notification form withing 7 days.

Healthy setting is then introduced to us. The definition of healthy setting is a place where everyone work together to achieve an agreed vision for the health and well being of worker and surrounding community. This program takes care of staff psychologically, socially and physically. A routine feedback is taken from staff on safe setting. This is to ensure health promotion and prevention are integrated into working environment.

This is all for today. Thanks for reading.

day 7 of DHO posting, at Kota Setar

Mr.Hassan Abidin(PPKPK),the person incharge of CDC unit, brief us regarding role of CDC unit. we were mainly discussing about

1. actions taken during an outbreak
2. how do they curb or control an outbreak

the next session was suppose to be a practical session,but since the staffs were involved in medical auditing,thre were unable to do so. however we just attended a short briefing session by Mr.Ooi(PPKP). topics of discussion were 'Qality assurance programme' and 'communicable diseases'.

during lunch time Dr.K.Narayanan togather with Dr.Sopna came to visit us. we had a discussion with them mainly about our daily activies. several questions were directed to us by Dr.KN

1. 1st ques: Why is there 2separate compartments within Ice Line Refrigerator(ILR)
2. 2nd ques: why Dt is given at 7years old and not DPt?

day 6 in kota setar

3/08/08

today our programme starts at 9am.we were given briefing by Tuan Hj Mansor (KPPKP),head of inspectorate unit regarding:

1. The function of Inspectorate unit, and
2. Activities conducted by NCD unit
3. Activities of investigation and prosecution unit

next session started after lunch break. it was also a short briefing session regarding:

1. Reinforcement of laws(peraturan-peraturan kawalan hasil tembakau)
2. E-notification

Last day in Padang Terap

Day 9 [6.8.2008]

Today we were under the BAKAS unit. We are briefed by Mr.Hassan about the unit and what are their responsibilities. It was very short session and further explanation is given on out field visit to few places that comes under observation of BAKAS.

* First we were shown the water pump which was situated in the health office premises itself. The officers also briefed us on how samples were taken from this water pumps for testing.

Then we proceeded to a remote village to see how daily household waste materials were disposed.

* First we saw the steps that waste sink water goes through before it is channeled to a nearby drain. It is called "sistem pelupusan air limbah" all the materials to buld it is provided by BAKAS.

* After that we were shown the toilet used there. We were told that the government supplies all the materials required to build the toilet free of charge. Then the villagers will have to built it them self. The health officers will monitor the progress and approve it.

* Later we were shown how fruits and other wet waste products are disposed. This waste products are usually put in a hold dug in the earth and then a metal cap is provided by the health office. This cap is so that flies and other insects do not enter the dug hole. When the hole is nearly full the cap is removed and hole covered with sand. Normally villagers will plant fruit trees on top of the covered hole.

* Then we also saw the burning method which is used to dispose waste materials.

Monitoring is done frequently to villages with such waste disposal methods as it is important to prevent diseases and maintain a health lifestyle.

After that we went to Puncak Jeniang waterfalls. Here we saw a man made dam. This dam supplies water to a nearby village which has around 169 houses. The water collects in this dam and then there is a filter placed before the water goes to the houses through pipes. The pipes are fixed in a way that water will reach the villagers in high pressure. According to Mr.Hassan, 3 inch pipe is fixed at dam and when it reaches the village it is just half inch in diameter.

After that we came back to the health office and ended our 2 weeks DHO posting in Padang Terap District Health Office with lunch prepared by the office.

Here we also would like to thank you all the officers that spent some of their time with us briefing everything we need to know.

thank you

MCH- d' Padang Terap Team

Day 7

Our 2^nd day on MCH clinic began with the short meeting with Family Medicine Specialist. He briefed shortly about the clinic which already briefed in detail by MNHO the previous day.

After the short meeting with FMS, we are explained by the staff nurse Aslizah about the antenatal check-up and we divided into 3 groups to observe the procedure that undertaken in routine antenatal check up.

The procedures are:

1. Walk-in into the clinic to get their number and also the antenatal card. (Normally follow-up cases because booking is done in “Klinik Desa”)

2. Then they’re required to have routine lab investigations such as Hb, RBS and urine examination. (HIV/VDRL test for new cases)

3. With the result of lab investigations, they will come to meet staff nurse for further check-up which will be done in two phase.

4. First phase – patient’s current height, weight and blood pressure measured (Pregnant ladies who had perceived quickening given ATT injection)

5. Second phase – patient will undergo routine abdominal examination and also will be counseled on pregnancy related problems such as anemia, spacing, diet and exercise.

During our visit, there are two patients receiving counseling on prevention of anemia and disadvantages for not having good spacing between pregnancies.

Besides counseling and routine abdominal examination, the staff nurse also in charge of dispensing hematinic medications and also iodine rich salt.

The hematinic drugs compromise of T.Vit B (Nicotinad 10mg; Riboflavin 1.5mg; Vitamin B1 1mg), T.Vit C 50mg, Folic Acid 5mg and Ferrous Fumerate 200mg.

Staff nurse in charge of the unit explained to us that, if the patients remain anemic in spite of consuming all the hematinics, they will be provided with softgel which having higher concentration of iron. They also will undergo serial counseling on food types that help in reducing anemia.

6. If any complications arise, then the patient will be referred to MO or FMS

Our expectation to follow JM to house visit for postnatal check-up is not fulfilled due to their busy day handling the antenatal check-ups.

DAY 3 :JITRA

Adolescent Health

Adolescent health specifically targets those between the age of 11 and 19 years old, with focus on sexual and reproductive health, growth and development, nutrition, mental and physical health.

Objective

1. Plan and provide health services to all adolescents which include the physical, mental and spiritual aspects to guide them towards a healthy life.
2. Prevent health problems due to risky behavior by promoting a healthy lifestyle.
3. Encourage adolescent involvement in healthy activities.

Standard Operating Procedure

1. Registration by Administrative Assistant.
2. New patients are given a screening form to fill up by Medical Assistant.
3. Antropometry(weight, height and BMI) measurements are done by Medical Assistant.
4. Screening form is assessed by Medical Assistant.
5. Further medical examination done by medical officer, if necessary.
6. Lab Test (hemoglobin and any specified test) done by Medical lab technician.
7. Referred to Family Medicine Specialist or other government agencies.
8. Given treatment, counseling and health education.
9. Next appointment given and asked to return home.

Activities

1. Identify, educate and treat adolescents with sexual and reproductive health problems( abnormal menstrual cycle, abdominal pain, mass, urogenital discharge, abnormal genitalia, sexual abuse, high risk behavior, and abnormal sexual orientation.)
2. Identify, educate and treat adolescents about nutrition.
3. Identify, educate and treat adolescents with mental health disorders( anxiety, stress, adjustment, behavioral, depressive and deviance)
4. Identify, educate and treat adolescents with high risk behavior( smoking, substance abuse, alcohol, vandalism, truancy, illegal racing)
5. Identify, educate and treat adolescent with physical health problems(acne, headache, non –intentional injury, and abdominal pain)

Records

Individual records are updated during visit along with screening form. Monthly records are prepared by MAs and biannual reports are sent to State Health Department on:
1. Number of new cases.
2. Number of old cases.
3. Types of morbidity.
4. Number of adolescents on treatment and counseling.
5. Number of referrals.
6. Number of screenings.

The team in front of the District Health Office in Jitra

DAY 2 : JITRA

Geriatric Health

Objective

To plan, prepare and provide services to all geriatric age- group patients encompassing physical, mental, social, and spiritual as well to reduce disability and increase independence.



Improve cooperation between Ministry of Health, NGOs and government agencies regarding geriatric health.

Enhance public knowledge and involvement with geriatric health.

Geriatric Health District Committee

Chairman : District Health Officer

Vice Chairman : Hospital Director

Secretary : Medical & Health Officer

Committee members : Family Medicine Specialist

Dental Officer

Dietician
Health Nurse
Medical Assistant
Physiotherapist


Their roles include planning activities, promotions, prevention, treatment for geriatric residents.

They also provide training for Health professionals based on official modules by the MOH and place them at Geriatric Units.

They also plan and implement suitable activities for the public based on the Geriatric Care Module.

They also encourage the involvement of the public in Geriatric Health Care through Geriatric Clubs, Fund raisers, Health Club and so on.

Inspect and analyze the achievement of this program.

Geriatric Clinic

The clinic runs concurrently with the regular Out-Patient Department and all geriatric patients are advised to undergo regular health examination every year.


Standard Operating Procedure
1. Registration is done by Administrative assistant.
2. History taking done by Medical Assistant
3. Initial examination (blood pressure, pulse rate, weight, height, body mass index, vision and hearing test) done by Medical Assistant
4. If necessary patient is referred to medical officer for further examination
5. Lab test (hemoglobin levels, random blood sugar and urine FEME) done medical lab technician.
6. If normal, patient may return home, if necessary treatment is provided.
7. Referrals are made to dietician, psychologist, family medicine specialist, dental officer, and social & welfare officer and nearest hospital.

Activities

1. Health Education at the health clinic, schools and community centres. This includes health talks, giving out flyers / posters and audio video presentation.
2. Screening, like BMI , pap smear , diabetes , hypertension , oral hygiene , breast examination , assessment of daily living
3. Treatment like counseling , physiotherapy, occupational therapy , stress management and home care nursing.

Records

Individual records are updated during every visit and every month the MA produces a monthly report. Every six months the medical assistant in charge of each health clinic sends a report to the State health deaprtment on :
1. Number of new patients
2. Numbers of repeat patient
3. Number of patient who were completely assessed.
4. Number of referrals
5. Number of each diagnosis.

From the left: A diagram of the district of Kubang Pasu(the biggest district in Kedah), Briefing at the meeting room.

DAY 4: JITRA

Role of Medical Assistants

Screening of patient
• History-taking.
• Vital signs examination.
• Physical examination.
• Lab investigation or X-ray

Examination, diagnosis and treatment
• Carrying out certain diagnostic and therapeutic procedures, such as ECG, nebulization, IV infusion.
• Carrying out certain minor procedure, namely application of POP, I&D and so on.• Giving injection.
• Taking IV blood sample.

Emergency treatment
• Involve in preliminary management during emergency.
• Conduct First Aids and CPR.
• Referral of cases to medical officer / nearest health centre.

Ambulance service
• Head the ambulance team.
• Responsible to ensure that all the equipments in the ambulance are in good condition.

Treatment of communicable diseases
• Case tracing.
• Case notification.
• Contact tracing.
• Provide treatment.
• Give immunization injections when needed.
• Home visits to defaulters and to give health education.

Immunization
• Examination and injection of Anti-Typhoid jab to food handler.
• ATT injection.
• Meningococcal injection to those going to perform Hajj.
• Japanese encephalitis vaccination
• Cholera injection.

After working hours
• Attend to emergency cases after working hours.

As assistant pharmacists
• Medication dispensing.
• Packing medicine.
• Recording medicine usage.