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334 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:325-338 health workers, which could promote physically active, use alcohol, consume less awareness among health care workers and fruits and vegetables, and had increased led to a low prevalence of hypertension perceived stress, i.e., known inducers of when comparing to this study (Osei-yeboah hypertension. Similarly, low education was et al., 2018). The study from Thailand significantly associated with hypertension demonstrates prevalence (35.27%) among Iranian health workers and Nepalese consistent with the current finding, where adults (Sahebi, Vahidi and Mousavi, 2010; the analogous working environment of Chataut, Adhikari and Sinha, 2011). A participants (in tertiary hospitals of urban consistent result was indicated in the past areas) might be a reason behind it (Sirinara, research (Schwenk, 2017). Hanprathet and Jiamjarasrangsi, 2019). Aryal et al (2014) reported 36.60% of The current study showed that being hypertension prevalence among Nepalese married was significantly associated with adult population aged ≥30 years, which is hypertension among health workers. A slightly higher than the current result. similar finding was noted from previous Comparing to the general population, it studies in Nepalese adult population and could be possible that health workers may health workers (Sahebi, Vahidi and have higher profound health knowledge, Mousavi, 2010; Dhungana et al., 2016). which leads to better health behaviours and Nepalese married people, especially disease prevention. females in urban areas, have busy and complicated life boost them to acquire In this study, increasing age was stressful life, low physical activity, and significantly associated with hypertension. unhealthy eating behaviours such as junk A similar result was reported by previous foods rather than fruits and vegetables (Ban, studies among health workers in Nigeria, 2018). A research evidence back-up the Thailand, and Ghana (Sumaila et al., 2016; current result by describing that the Osei-yeboah et al., 2018; Sirinara, transition from single to married life Hanprathet and Jiamjarasrangsi, 2019). possesses lifestyle modification such as Nepal demographic health survey 2016 sedentary lifestyle, which adversely revealed the same finding that increasing impacts their blood pressure resulting in age was significantly associated with hypertension (Wood, Goesling and Avellar, hypertension among Nepalese adults 2007). (Kibria et al., 2018). It was physiologically evident that older people are inevitable to Low fruits and vegetable get hypertension, a result of gradual consumption was found to be a significant changes in the cardiovascular system; predictor of hypertension among health vascular remodelling, arterial stiffness, and workers in this study. Fruits and vegetable endothelial dysfunction (Alghatrif et al., are a great source of potassium, which helps 2013). to prevent hypertension by maintaining renal homeostatic function (Wu and Wolley, A current study found that health 2019). A meta-analysis reported a similar workers having TSLC level of education association of low fruits and vegetable were at high risk of hypertension than consumption with hypertension among the health workers with post-graduate or higher Asian population (Li et al., 2016). Previous education. Health workers with TSLC studies in the Nepalese adult population education tended to have limited health found no association of fruits and vegetable knowledge as they learned only 18 months consumption with hypertension (Dhungana of basic health courses (Council For et al., 2016; Khanal et al., 2017; Neupane Technical Education and Vocational et al., 2017). The unhealthy working Training, 2020). Furthermore, analysis of environment (shift work, stress, high current findings revealed that health workload, unavailability of fruit and workers with TSLC education were less vegetable in the workplace) of the health

Prakash Ghimire, Alisha Khadka, Amornrat Anuwatnonthakate and Supaporn Trongsakul, Prevalence... 335 workers force them to consume less fruit consume more alcohol. and vegetable than general people. The Regarding perceived stress, the study setting of this study was in Kathmandu valley, Nepal, where unhealthy current study found a significant eating behaviours are in increasing trend, association between increased perceived i.e., people prefer to eat easily available stress and hypertension. Research junk foods instead of fruits and vegetables supported this association by stating that (Resource Centre for Primary Health Care, stress causes abnormal activation of the 2016). sympathetic nervous system alters hormonal cascades, which increases blood This study found the association pressure, cholesterol levels, fibrinogen, and between low physical activity and blood fluidity leads to cardiovascular hypertension in health workers. Ibrahim events, including hypertension (Mucci et stated that inadequate physical activity al., 2016). Previous studies among the alters blood pressure homeostasis resulting general population demonstrated similar in hypertension (Ibrahim, 2018). A findings that the increased perceived stress consistent result was observed in the studies was a significant factor of hypertension among the Nepalese population and (Redmond et al., 2013; Bhelkar et al., Nigerian health workers (Chataut, Adhikari 2018). The past studies in Indian health and Sinha, 2011; Dhungana et al., 2016; workers and Brazilian health workers Sumaila et al., 2016). Biddle found that less observed consistent finding with the current physically active individuals experience research (Owolabi et al., 2012; Leonelli et more stress in their life, which is also a al., 2017). Health workers have dual crucial inducer of hypertension (Biddle, responsibility towards their work setting, 2016). Health workers of central hospitals and home laid them prone to get high in this study mainly use vehicles for perceived stress. The health workers in this transportation and deal with high workload study deal with the high flow of patients in with less or no physical movement makes hospitals and family issues, which lodged them less physically active the whole day. them to experience more stress. The current study found the This study is equipped with several association of alcohol use with strengths. Firstly, it is a novel study that hypertension among health workers. It was uncovered the hidden burden of theoretically evident that alcohol use causes hypertension in Nepalese health workers. vasoconstriction action and alteration in the Secondly, health workers were benefited renin-angiotensin-aldosterone system, from this study as they had a chance to which ultimately leads to alcohol-induced know their hypertensive status and take hypertension (Crestani et al., 2014). With preventive measures on time. Lastly, study several reasons such as culturally findings added up the health data of health acceptable in ethnic groups, peer pressure, workers that would help different scholars stressful married life, family history of for further studies. Nevertheless, this study alcohol use, and smoking status, alcohol has a limitation on its study design. This use is aggressively prevalent among the study applied the cross-sectional study Nepalese population, especially in urban design, which cannot prove the real causal areas like Kathmandu. The percentage of relationship of disease, but appropriate to alcohol use was found to be higher among determine the prevalence. the health workers (59.20%) in this study than the national figure among Nepalese CONCLUSION adult population (26.5%) (Aryal et al., 2014). Based on the current findings, it was High prevalence of hypertension found that increased perceived stress with its modifiable factors (educational among health workers direct them to level, fruits and vegetable consumption,

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AN OVERVIEW OF DEPRESSION TENDENCIES IN PATIENTS WITH TYPE 2 DIABETES MELLITUS IN KEBONSARI PRIMARY HEALTHCARE CENTER, SURABAYA CITY Iftitah Shofiyati Departement of Epidemiology,Faculty of Public Health, Airlangga University, Surabaya, Indonesia Corresponden Address: Iftitah Shofiyati Email: [email protected] ABSTRACT Type 2 diabetes mellitus (DM) occurs due to insufficient insulin production or insulin resistance in the human body. Type 2 DM also causes physical weakness, vision problems, risk of death, and depression. This study aimed to describe depression tendencies in patients with type 2 DM under treatment in Kebonsari Primary Healthcare Center, Surabaya city. This study was a descriptive study with a cross-sectional approach. The research samples were 74 people with type 2 DM in the Kebonsari Primary Healthcare Center, Surabaya city. These respondents selected using simple random sampling had met the inclusion criteria. These repsondents were aged more than 25 years old, did not experience psychological disorders, and had suffered from type 2 diabetes mellitus for 5 years. The data analysis was done using a univariate analysis by looking at the frequency distribution of variables. The results indicate that the prevalence of patients with type 2 DM who tended to experience depression was at 50%. The majority of patients with type 2 DM who experienced depression were women (47.4%) and elderly (aged 46-65 years) (41.9%). Most of them had low education levels (62.2%), and some respondents had complications (37.8%) and poor family support (62.2%). Support from closest people such as family support can improve the adaptation of patients with the disease and can prevent psychological disorders, especially depression in patients with type 2 DM. Keyword: type 2 diabetes mellitus, family support, depression tendencies. ABSTRAK Penyakit diabetes mellitus tipe 2 adalah sebuah kondisi karena insulin yang diproduksi tubuh tidak cukup atau tubuh mengalami resistensi insulin. Diabetes mellitus tipe 2 dapat menyebabkan timbulnya kelemahan pada fisik, gangguan pengelihatan, risiko kematian dan depresi. Penelitian ini bertujuan untuk mengetahui gambaran tingkat kecenderungan depresi pada penderita diabetes mellitus tipe 2 di Puskesmas Kebonsari Surabaya. Penelitian ini adalah penelitian deskriptif dengan pendekatan cross sectional. Sampel berjumlah 74 penderita diabetes mellitus tipe 2 di Puskesmas Kebonsari dan termasuk dalam kriteria inklusi yang telah ditentukan, yaitu berusia lebih dari 25 tahun, tidak mengalami kelainan jiwa dan menderita diabetes mellitus tipe 2 selama lima tahun. Pengambilan sampel dilakukan dengan teknik simple random sampling. Teknik analisis data yang digunakan adalah analisis univariat dengan melihat distribusi frekuensi variabel. Hasil menunjukkan bahwa prevalensi penderita diabetes mellitus tipe 2 yang mengalami kecenderungan depresi sebesar 50%. Responden yang mengalami kecenderungan depresi sebagian besar adalah perempuan (47,4%), merupakan kelompok usia lansia (46-65 tahun) (41,9%), memiliki tingkat pendidikan yang rendah (62,2%), memiliki komplikasi (37,8%) dan mendapat dukungan keluarga yang rendah (62,2%). Dukungan dari orang terdekat salah satunya dari keluarga dapat meningkatkan adaptasi penderita dengan penyakitnya serta dapat mencegah timbulnya gangguan psikologis utamanya depresi pada penderita diabetes melitus tipe 2. Kata kunci: diabetes mellitus tipe 2, dukungan keluarga, kecenderungan depresi. INTRODUCTION organ to produce insulin to fulfill the body's needs or due to the disability of the body to Diabetes mellitus (DM) causes effectively use the insulin produced metabolism disorders that lasts years and (Indonesian Minsitry of Health, 2014). occurs due to the disability of the pancreatic ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.339-347 Received 16 July 2019, received in revised form 5 September 2019, Accepted 18 October 2019, Published online: December 2020

340 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:339-347 According to the Centers for Disease diabetes. For example, they may not follow Control and Prevention (2017), diabetes is the dietary advice, do physical activity, stop divided into three types, namely type 1 smoking, and comply with the treatment diabetes, type 2 diabetes, and gestational schedule (Riley, et al. 2009). diabetes. In 2003, 194 million people suffered from DM , and the number increased Additionally, DM can worsen to 200 million people in 2005 and 210 million depression symptoms. Stress due to concerns people in 2010. The International Diabetes in controlling diabetes and the effects of Federation (2013) report 5.6 million people in diabetes on the brain can contribute to Indonesia suffered from diabetes in 2000, and depression. In the United States, a person who the number reached 8.5 million people in has diabetes mellitus is twice as likely to 2013. It is predicted to rise to 14.1 million suffer from depression than general people. people in 2035. Further, the Indonesian At the same time, the depression symptoms Ministry of Health (2013) shows that the DM may reduce physical and mental health. For prevalence that mostly occurs to people at the example, overeating causes an increase in age of >15 years in Indonesia was at 1.5 body weight which is one of the risk factors percent. Specifically, in East Java province, for diabetes. Exhaustion and worthlessness the DM prevalence exceeded the national may cause a person to ignore the special diet prevalence at 2.1 percent. or medication needed to control diabetes. A study shows that people with diabetes and The number of DM incidents in depression have more severe diabetes Surabaya city steadily kept rising from 2016 symptoms compared to people with only to September 2018. The data from Surabaya diabetes (National Institute of Mental Health, District Health Office (2018) show that in 2011). 2016 the number of DM incidents was 105,208 incidents, which decreased to Diabetes and depression correspond 102,599 cases in 2017, while in September to each other. Depression may contribute to 2018 it bounced back to 115,460 incidents. the low control of diabetes, its complications, The highest number of patients with DM and inadequate management of depression. (4,060 incidents) in Surabaya received Irregular control of diabetes will cause the treatment n from January to September 2018 blood glucose level to exceed its normal in Kebonsari Primary Healthcare Center. limits and finally result in various complications (Fatimah, 2015). Ceaseless According to Handayani and Dewi DM complications may lead to prolonged (2009), people diagnosed with DM may depression. Chronic complications and experience physical and psychological difficulty of recovery in people with DM can disorders. These psychological disorders lead to depression. Complications will limit include depression, anxiety, irritability, one's activities in daily life and cause irritability, and loss of will or interest to live. prolonged depression. As stated by the WHO, depression is a mental disorder that causes several symptoms such A study by Ramdani (2016) shows as the feeling of depression, loss of joy and that patients with type 2 DM experienced a interest, guilty feeling for things, low self- certain degree of depression. As many as esteem, horrible eating and sleep habits, 82.3% patients had no depression symptoms, difficulty in concentrating, and loss of 15.2% experienced mild depression, and energy. The effects of depression start to 2.5% were moderately depressed. Research at trigger when someone has been diagnosed Ambarawa Regional Hospital by with diabetes mellitus. Patients will behave Kuminingsih (2013) showed 37.7% patients contrary to prohibitions to control their with DM experienced mild depression,

35.8% had moderate depression, and 26.4% Iftitah Shofiyati, An Overview On Depression... 341 had severe depression. with type 2 DM. To be selected as the Essentially, several factors such as repsondents, patients were over 25 years old, physical, psychological, and social factors had no history of mental illness, suffered related to DM and its therapy may also trigger from type 2 DM for over five years or more, depression. Patients with DM who are and were willing to participate in this study. depressed due to their chronic disease may While patients who were unwilling to experience depression (Supriati, et al. 2016). participate were excluded from the list. The The lack of social support and feeling of inclusive respondents were selected using a denial towards their conditions may distress simple random sampling method. people with type 2 DM (Semenkovich et al., 2015). This study utilized demographic and family support as independent variables and Involving social support is one of the depression tendencies as a dependent care management of depression associated variable. This study collected data through with DM. Patient interactions with their questionnaire-based interviews by visiting social environment play a role in increasing patients’ hourse from doors to doors. their adaptation in accepting and controlling their disease. One of the social support forms The demographic variables consisted is sfamily support (Isworo and Saryono, of age, gender, education level, and 2010). complications. The age variable were then divided into two groups, namely adult age A patient whose family is involved in group (26-45 years old) and elderly group the diabetes care will feel supported and (46-65 years old). The gender variable was motivated to cope with their condition. divided into male and female. The education Patients with DM may feel physical and level variable was categorized into low psychological comfort when receiving family education (not attending school, elementary support. It also helps them increase school, and junior high school graduates) and confidence to survive. Family is expected to higher education (high school and university always provide motivation, facilities and graduates). companionship to patients with DM, and thus they will feel loved and cared for doing The family support variable was activities independently (Supriati, et al. measured using the Hensarling Diabetes 2016). Family Support Scale (HDFSS). This instrument was developed by Hensarling in Based on the issue above, this study 2009. It can measure patient’s perceptions of identified depression tendencies that people family support they received so far. The with type 2 DM experienced. family support variable consisted of some dimensions, such as emotion, appreciation, METHOD instrument, and information dimensions. It was poured into questions consisting of 29 This study applied a descriptive items with alternative answers worth t 1-4 research design with a cross-sectional points. Family support was considered low if approach. It was conducted within 2 months the score obtained was smaller than the mean starting from May to June 2019 in Kebonsari (score of <76.9). While it was considered Primary Healthcare Center in Surabaya city. high if the score was the same or more than The research population included patients the mean (score of ≥76.9) with type 2 DM who underwent treatment in Kebonsari Primary Healthcare Center. The Furthermore, the depression tendency research samples involved were 74 people variable was measured using the Beck Depression Inventory (BDI) instrument created by Aaron T. Beck. This questionnaire

342 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:339-347 was applied to measure how severe one’s depressed, and 4.1% experienced a severe depression was, but it was not a diagnosis depression tendency. tool. The BDI questionnaire evaluated 21 depression symptoms which 15 symptoms Table 1. Depression Tendencies among described emotions, 4 symptoms described Patients with Type 2 DM in attitude change, and 6 symptoms were Kebonsari Primary Healthcare somatic symptoms. Each symptom was Center. ranked on a 4-point scale, and its value was summed to give a total score of 0-63. The Depression Tendencies assessment of depression tendencies wasbased on the scores obtained. A value or Variables Severe Moderat Mild Normal score of <10 indicated no depression e tendencies (normal), 10-18 suggested a mild depression tendency, 19-29 indicated a n% n % n % n % moderate depression tendency, and >30 showed major depression tendency.The data Gender analysis technique applied was the univariate analysis which presented the results in in -Male 0 0 0 0 2 2.7 21 28.4 frequency distribution tables narratively. This study has obtained an ethical proval from the -Female 3 4.1 7 9.5 25 33.8 16 21.6 Ethics Commission of Faculty of Public Health Airlangga University (No. Age 2 2.7 1 1.4 3 4.1 5 6.8 139/EA/KEPK/2019). -26-45 yo 1 1.4 6 8.1 24 32.4 32 43.2 -46-65 yo RESULTS Education Depression tendencies based on gender -Low 2 2.7 4 5.4 22 29.7 18 24.3 From gender perspective, depression tendencies mostly occurred to female -High 1 1.4 3 4.1 5 6.8 19 25.7 respondents (47.4%). Most female respondents (33.8%) experienced a mild Complicati depression tendency, 9.5% felt a moderate depression tendency, and 4.1% tended to on 2 2.7 4 5.4 22 29.7 9 12.2 have severe depression. While of 23 male -Yes 1 1.4 3 4.1 5 6.8 28 37.8 respondents, most of them did not experience -No depression tendencies. Only 2.7% of the male respondents experienced mild depression. Family The results of depression tendencies Support are summarized in Table 1. The measurement of depression tendencies experienced by - 3 4.1 6 8.1 22 29.7 15 20.3 patients with type 2 DM using the BDI questionnaire show that 50% of the Inadequate respondents tended to experience depression. - Adequate 0 0 1 1.4 5 6.8 22 29.7 Most respondents (36.5%) experienced a mild depression tendency, Total 3 4.1 7 9.5 27 36.5 37 50 9.5% of them tended to feel moderately Depression tendencies based on age According to age groups, most respondents who experienced depression tendencies were in the age group of 46-65 years old (the elderly age group). Of 63 respondents in the elderly group, 41.9% of them experienced depression tendencies. As many as 32.4% of them experienced a mild depression tendency, 8.1% experienced a moderate depression tendency, and 1.4% experienced a severe depression tendency.

Depression tendencies based on education Iftitah Shofiyati, An Overview On Depression... 343 level 21% of the respondents experienced mild The results show that the majority of depression, 12% experienced moderate respondents had low education (62.2%). This depression, and 18% felt severe depression. study reveals 29.7% of them experienced a mild depression tendency, 5.4% of In contrast, Ramdani (2016), who respondents experienced a moderate examined the level of depression of people depression tendency, and 2,7% others had a with type 2 DM at the Kardinah District severe depression tendency. General Hospital of Tegal district, shows mild depression occurred to 15.2% of the Depression tendencies based on patients, 2.5% of the patients experienced complications moderate depression, and none (0%) had major depression. Another variable discussed was complications. This study shows that the People who experience depression majority of the respondents who experienced tendencies often feel upset and worried about depression tendencies previously had the future due to their diseaseThey also complications (50%). In details, 29.7% of experience sleeping disorders as they need to them experienced a mild depression wake up to urinate at night for more than 3 tendency, 5.4% experienced a moderate times due to the high blood sugar levels. They depression tendency, and 2.7% others had a also sometimes feel tired and less energetic. severe depression tendency. Diabetes and depression correspond Depression tendencies based on family to each other. Depression can contribute to support the inadequate control of diabetes. Diabetes and its complications also contribute to poor Family support consisted of four management of depression. Depressive dimensions, namely emotion, appreciation, events may have the risk of depression instrument, and information dimensions. symptoms to appear again. A study shows a Based on Table 1, 62.2% of the respondents person with DM and depression is more received less family support. Among the prone to recurrent depression when being respondents who received lower family observed for five years (Lutsman, et al. support, 29.7% of them experienced a mild 2000). depression tendency, 8.1% experienced a moderate depression tendency, and 4.1% had Distribution of depression tendencies by a severe depression tendency. gender perspective DISCUSSION The results show that most depression Overview of depression tendencies in tendencies occurred to female respondents patients with type 2 diabetes mellitus (47.4%). Ramdani (2016) shows similar results by mentioning that the percentage of In Table 1, this study presents the depression tendencies in females was 53,2% prevalence of depression tendency in people higher than in males at 46.8%. Research with type 2 DM was 50%. It is in line with conducted by Ramanda (2014) also proves research conducted by Anderson et al., (2001) that the highest depression prevalence who find 48% of the respondents experienced occured to females (20%). Another study depression due to DM. Further, research further finds depression prevalence was conducted by Mufidah (2018) shows that higher in female patients (33.9%) than male patients (29.9%) (Rajender, et al. 2016). A meta-analysis study conducted by Anderson, et al. (2001) discovers that diabetes increased

344 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:339-347 the risk of depression twice higher in females Distribution of depression tendencies (28.2%) than males (18%). based on education level Depression is a psychological Reagrding education levels, this study disorder related to long-term stressors such as chronic diseases, including diabetes mellitus. indicates the majority of respondents had a Men and women performa different attitudes to dealing with the stressors. as men tend not low education level (62.2%). This is to be emotional in coping with a problem, they will prefer to solve a problem directly. consistent with research conducted by Whereas women outweigh emotion, and thus it can make women more difficult to deal with Ramanda (2014) stating that the majority of stress (Mujabi, 2017). respondents with low education experienced Distribution of Depression Tendencies from Age Perspective depression (20%). However, it differs from Based on the results, most research done by Sari (2016) pointing out the respondents in the elderly group (aged 46-65 years) mostly experienced depression fact that the majority of respondents tendencies (41.9%). In similar way, research by Ramanda (2014) states that a quarter of the experiencing depression were highly respondents at the age group of 46-65 years experienced depression. Research conducted educated (59%). by Mufidah (2018) also indicates the highest depression tendencies occurred to patients According to Sativa (2015), there was with type 2 DM under 60 years old. High depression rates in this age group might be a negative relationship between education caused by a decrease in health and a sense of worry about the future. Depression may level and depression tendencies in people reduce patient motivation to seek for treatment and to practice self-care and cause with type 2 DM. The higher education level, their blood sugar to be uncontrolled and (Egede and Ellis, 2009).Female elderly have the lower the degree of depression. Adequate more possibilities to experience depression tendencies due to hormonal changes that education levels can help patients understand cause menopause (Vamos, et al. 2009). Elderly patients with DM usually experience their condition, disease, and risks related to various health problems and undergo various kinds of health treatment. They generally feel DM (Mufidah, 2018). alienated (isolated), worried about their future, declining health, and disability due to Research conducted by Rajender et al. age (Rihmer and Angst, 2005). It is difficult to distinguish deterioration in elderly’s (2016) shows that education level was physical condition due to the progression of the complications or old age. associated with depression in people with type 2 DM. Low education level, especially illiteracy, may lead to lack of awareness of disease severity, routine medication, and dietary consumption which contribute to complications (Rajender, et al. 2016). Depression often occurs in low-educated people with DM (Vamos, et al. 2009). Low education can correspond to low economy, indecent living place, unemployment, and difficulties to get a permanent job, which may encourage depression (National Collaborating Centre for Mental Health, 2010). Low education level was a risk factor for depression in people with chronic diseases, including diabetes mellitus. Lack of knowledge about the disease and its management, as well as insufficient exposure to information about coping mechanism may also cause depression (Supriati, Nasution and Ilmansyah, 2016).

Distribution of Depression Tendencies Iftitah Shofiyati, An Overview On Depression... 345 Based on Complication families can change and improve the There were 37.8% of the respondents perception of the patients towards the disease who had complications and experienced more positively (Sari, 2016). depression tendencies. These complications varied, such as high blood pressure, vision Family support also help DM patients problems, leg injuries, and stomach disorders. more disciplined in maintaining the Mufidah (2018) finds that the prevalence of healthcare management (Mufidah, 2018). depression and complications at the same Lack of family support can cause time occurred to 51 patients (52%). Anxiety incompliance with dietary restrictions; hence, and lack of knowledge may pressure a person the disease can be controlled (Susanti, 2013). to deny the changes that occur. As a result, a denial can worsen one's blood sugar control, Family support and care will provide thereby increasing the risk of complications DM patients a sense of comfort, attention, and depression. Diabetes complications will compassion, and will foster patient to recover cause nerve damage, increase blood by accepting their condition. Another study viscosity, and impair the metabolism of fat conducted by Yusra (2011) finds that based (Mufidah, 2018). on interviews with five people with type 2 DM, two of them had been exhausted with Purwanti (2013) mentions when DM their condition for burdening their family, patients had wounds on feet, they would be at and three others had difficulty in practicing greater risk of experiencing depression than religious rituals and received less attention DM patients without wounds. Foot sores have from their family. Family support can caused unpleasant smell and often make encourage patients to take their medication patients feel inferior and ashamed. As a regularly according to the dose on doctor’s result, patients tend to isolate themselves and instruction (Meidikayanti and Umbul, 2017). have difficulties to get along with neighbors. Research conducted by Rehman and Kazmi CONCLUSION (2015) shows that there was high prevalence of depression, fear, and anxiety experienced A hald of total patients with type 2 by people with type 2 DM complications. DM in Kebonsari Primary Healthcare Center experienced depression tendencies. Most Distribution of depression tendencies respondents who experienced depression based on family support perspective tendencies were female and in the elderly age group (46-65 years old) and had low The results show that the majority of education levels and inadequate family the respondents received inadequate family support. support (62.2%), and nearly half of them experienced depression tendencies. Research Family as the closest people to conducted by Supriati, Nasution, and patients with DM should always provide Ilmansyah (2016) finds that although the adequate support by motivating, facilitating, majority of respondents received sufficient and accompanying them so that they could family support, nearly half of them still calm themselves for accepting their condition experienced mild depression. Garousi and and be encouragous to do their daily activities Garrusi (2013) state that supportive family independently and manage their health. behavior is a form of social support to avoid depression and anxiety to reduce stress. REFERENCES Interaction between patients and their Anderson, R. J. et al. (2001) ‘The Prevalence of Comorbid Depression in Adults with Diabetes: a meta-analysis’,

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THE ROLE OF HEALTH DIAGNOSIS ON GYMNASIUM NEEDS OF STUDENTS OF UNIVERSITAS AIRLANGGA, SURABAYA Ragilia Indah Lutfiana1, Sonny Marsetyo1, Pitasari Nastiti1, Ernawaty1 1Department of Health Administration and Policy, Faculty of Public Health, Airlangga University, Surabaya, Indonesia Correspondence Address: Ragilia Indah Lutfiana Email: [email protected] Email: [email protected] (082216009813) ABSTRACT Gymnastics is exercises in which physical activities and playing activities take place. At the same time, the nervous system works as a stimulant conductor in the form of coordination of muscle function. A gymnasium is prominent for university students as they need to be fit and healthy to do tasks given at the campus. This study aimed to identify gymnasium needs for students and the role of clinical diagnosis on the needs of students for a gymnasium at Universitas Airlangga, Surabaya. The research method was quantitative. The research population was all students of Universitas Airlangga, Surabaya. While the samples were chosen using nonprobability snowball sampling. This study utilized questionnaires as a primary data collection tool to understand gymnasium needs of the students of Universitas Airlangga. The results indicate the students equired private gymnasium facilities such as swimming pools and cafeterias which only could be accssed by the society of academicians at Universitas Airlangga. This study concluded that the students were advised by doctors to do swimming which was their desired sport. Keywords: need assessment, gymnasium, clinical diagnosis, swim. ABSTRAK Gimnastik merupakan senam di mana aktivitas gerak badan dan keterampilan bermain diterapkan. Pada saat yang sama, sistem syaraf bekerja sebagai penghantar rangsang dalam bentuk koordinasi fungsi otot. Gimnasium sangat penting bagi mahasiswa, dikarenakan mahasiswa harus ada dalam kondisi sehat untuk melaksanakan tugas yang diberikan di kampus. Penelitian ini bertujuan untuk mengetahui kebutuhan gimnasium dan pengaruh diagnosis klinis terhadap kebutuhan gimnasium mahasiswa di Universitas Airlangga, Surabaya. Metode penelitian yang digunakan merupakan metode kuantitatif . Populasi penelitian adalah seluruh mahasiswa di Universitas Airlangga, Surabaya. Sedangkan sampel dipilih menggunakan nonprobability snowball sampling. Kuisioner digunakan sebagai alat pengumpulan data utama untuk memahami kebutuhan gimnasium mahasiswa Universitas Airlangga. Hasil menunjukkan bahwa mahasiswa memerlukan fasilitas gimnasium privat seperti kolam renang dan kafetaria yang hanya diakses oleh civitas akademika saja. Penelitian ini menyimpulkan bahwa mahasiswa Universitas Airlangga Surabaya mengikuti saran yang diberikan dokter untuk melakukan olahraga berenang dan ini sesuai dengan kebutuhan olahraga mahasiswa. Kata kunci: penilaian kebutuhan, gimnasium, diagnosis klinis, renang. INTRODUCTION for concentration, memory, and intellectuality. Takdir D., Mahmudin (2008) Gymnastics is exercises in which mention four important effects of physical physical activities and playing skills take a activities in increasing knowledge and place. At the same time, the nervous system thinking processe. First, physical activities works as a stimulant conductor in the form of may increase the circulation of neurons that coordination of muscle function. In this make a person get more oxygen and nutrients regard, Trudeau (2008) emphasizes that in the brain. Second, these stimulate the activities also improve important functions production of neurotransmitters that can ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.348-355 Received 1 July 2019, received in revised form 10 July 2019, Accepted 17 September 2019, Published online: December 2020

Ragilia Indah Lutfiana, Sonny Marsetyo, Pitasari Nastiti and Ernawaty, The Influence Of Clinical... 349 improve mood and foster Brain-Derived Notoatmojo further explains that someone Neurotrophic Factor (BDNF) factors. Third, will do an action if he behaves towards an these facilitate a process of new brain cells so- object positively and believes that someone called neurogenesis, and the fourth effect of else wants him to take it. Theory of planned physical activities is to improve visual acuity. behavior explains beliefs influence attitude, Sunadi (2018) also states that fitness subjective norms, and perceived behavioral positively influences student achievement. control. These three components interact and become determinants of intentions for A fitness center or gymnasium is is someone to act (Azwar, 2007). It suggests that popular because it provides a variety of tools someone who receives health diagnosis will and facilities that have been designed probably decide on action they will take. properly for physical training (Muttaqin, Ifwandi, and Jafar 2016). Besides, a The establishment of a gymnasium in the gymnasium is also very easy to find because campus area is vital for students because it now many entrepreneurs invest in facilitates students with healthy activitiesat gymnasiums. Gymnasium businesses have campus. Saqurin (2013) ever found only 3 out been mushrooming, especially in big cities. It of 10 students on average at Universitas is not surprising that competition in gym Airlangga routinely did sportsThis study businesses arises quite fiercely. More and investigated students at Universitas Airlangga more gymnasiums are established, and thus to further know gymnasium needs of the the management must design certain students and identify whether health diagnosis strategies to offer gymnastic service products. could affect their gymnasium needs. From the research background above, this study aimed Moreover, the gym management must be to determine needs of gymnasium and the role able to sound marketing strategies to attract of health diagnosis on gymnasium needs of consumers as many as possible and to students at Universitas Airlangga, Surabaya. maintain the market share through th profit gain ((Makmur and Widagdo 2017). Various METHODS managerial efforts must be done, for example providing adequate facilities such as a This study employed a descriptive- comfortable, safe, and strategic room, quantitative method. It used questionnaires as complete weight training equipment for a primary data collection tool to understand training needs, and excellent customer gymnasium needs of students at Universitas service. Besides, a gymnasium must have an Airlangga. appropriate and accurate training program as well. The research population was all active students (undergraduate, graduate, and People will show positive or negative doctoral students) at Universitas Airlangga. behavior towards a new trend including the Population is all elements that have some mushrooming gymnasium businesses. common characteristics (Malholtra, 2004; Notoatmojo (2003) defines that behavior is Rinawiyanti et al. 2014). The samples were related tohow a person responds to pain and chosen using nonprobability snowball disease from himself and from external sampling. The selection of the smaples started factors. Kinds of responses include both from a small number, and those who agreed to passive responses (knowledge, perception, join recommended their colleagues to be the and attitude) and active responses (practice) next respondent. The sampling was towards pain and disease. A person's behavior conducted in seven days and finally found 121 towards pain and disease corresponds to the respondents consisting of 20 males and 101 levels of overall disease prevention measures. females.

350 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:348-355 RESULTS Besides, this study finds the majority of the respondents liked sports (88 people). Perceived Components (Subject assessment) Table 4. Distribution Frequency of This component discusses individual Respondents by Reasons on Sports subjective factors that can influence needs. Favoritism. This study includes individual characteristics such as gender, age, desires, attitudes, and Reasons Total beliefs stowards health. To have it as a hobby 10 To make body healthy 65 To maintain weight 13 Table 1. Distribution Frequency of To do it as a lifestyle 2 Respondents by Gender. To overcome stress 2 Gender Total To improve our sleep 5 Male 20 quality Female 101 Total 121 To do it as needs 1 Dislike sports 1 No answer 31 Explained that respondents were The results indicate most of the dominated by women as many as 101 people while men were only as many as 20 people. respondents liked sports because they wanted This shows that the majority of women who want a gymnasium. to maintain their body health (65 people). This study shows most of the Moreover, this study finds that the respondents were aged 21-30 years old (75 people), and the 17-20 age group was the most favored sports was swimming (58 second dominant respondents (38 people). It suggests that those who were interested in a people). gymnasium were the adult age group. Table 5. Frequency Distribution of Respondents by Favorite Sports. Table 2. Distribution Frequency of Sports Total Respondents by Age. Basketball 1 Total Self-defense 1 Age 38 Swimming 58 17-20 years 75 Cycling 2 21-30 years 6 Jogging/walking 3 31-40 years 2 Cardio 28 41-50 years Treadmill 35 Weight gain 16 Table 3. Distribution Frequency of Weight loss Respondents by Sport Favoritism. Yoga 33 people Volleyball 1 people 2 people Sports Favoritism Total Health diagnosis of students at Universitas Yes 88 Airlangga No 32 This study addresses external factors that can also influence needs. These referred to physical ability of individuals and resources including the availability of

Ragilia Indah Lutfiana, Sonny Marsetyo, Pitasari Nastiti and Ernawaty, The Influence Of Clinical... 351 facilities that support health measures and Given that the majority of the respodnents had health problems, this study health diagnosis. The health diagnosis reveals that 68 people did not go for medical check by doctors. It means the students tend identifies health problems and involves to be less aware of their health issues. doctor’s advice. Table 6. Frequency Distribution of Table 9. Doctors’ Recommendations of Respondents by Health Problems. Sports for Respondents. The existence of health Total Sports Total problems recommendation by Yes 44 people 1 people No 76 people doctors 21 people 1 people This study does not find any health Basketball 5 people issues in most of the repsondents (76 people). Swimming 7 people There were 44 respondents who were required Yoga 11 people to do exercises. Jogging/walking 11 people Cardio 1 people Table 7. Types of Health Problems Occuring Treadmill 10 people to Respondents. Weight loss 68 people Light exercise Types of health problems Total No recommendation Allergy 1 people Not seeing a doctor Anemia 10 people Asthma 3 people This study shows that the majority of Hypertention 1 people the respondents who had health issues were Indigestion 17 people advised to do swimming (21 people). Eleven Acne 2 people respondents were advised to exercise on a Overweight 42 people treadmill, and the remaining were advised to Obesity 9 people do exercises for weight loss. Wasting 11 people Irregular menstrual cycle 2 people The role of health diagnosis on gymnasium Bone abnormalities 1 people needs Tiredness 2 people Sprain 1 people Table 11 presents that out of 120 Constipation 1 people respondents, as many as 97.50% of the No problems and noanswer 17 people respondents required a gymnasium at Universitas Airlangga. The respondents were mostly overweight (42 people). Table 8. History of Respodents’ Health Table 10. Gymnasium Needs of Checks by Doctors Respondents. History of health Total Gymnasium needs Total checks Yes 117 people Yes 53 people No 4 people No 68 people

352 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:348-355 Table 11. Types of Gymnasium Facilities which only can be accessed by the society of Required. academicians at Universitas Airlangga. Gymnasium Total Table 14. Seperation of Gymnasium Rooms facilities 91 people by Gender. 67 people Swimming pool 33 people Gymnasium rooms Total Cafeteria 32 people by gender Jacuzzi Yes 91 people Sauna 9 people No 21 people Lifting Weights, Gym Equipment, 6 people Table 15. Preference on Gymnasium Users. Fitness Equipment Jogging Track, 3 people Gymnasium users Total Tennis, Badminton, 1 people Society of academicians 73 people Volleyball, Society of academicians Basketball, Treadmill and public 47 people Yoga, Pilates, Zumba Changing room DISCUSSION Regarding desired gymnasium Needs assessment is the process of facilities, the majority of the respondents determining priority needs. Seel and Glasgow required pool (75.83%). explain that needs are discrepancies between what is available and what is available with Table 12. Required Gymnasium Concept. what is expected. Need assessment is the process of gathering information about gaps Gymnasium Total and determining gap priorities to be solved Concept \"(Rinawiyanti et al. 2014). 41 people Indoor 3 people Kaufman and English define needs Outdoor 76 people analysis as a formal process to determine a Indoor and Outdoor gap between actual outputs and impacts with the desired outputs and impacts, place these This study informs that 63.35% of gaps in priority scales, and then choose respondents preferred indoor and outdoor prioritized gaps to be resolved (Makmur and gymnasium. Widagdo 2017). Need analysis can be useful for identifying problem solutions. Table 13. Need For Sports Coach. Predisposing factors are factors that Need for sports Total make them possibly determine what is needed coach (Samudin and Sasmito 2017). In other words, Yes 56 people needs are the basis and direct stimulus for No 64 people using health services. Needs are divided into two categories: perceived needs or perceived As many as 64 people did not need a (subject assessment) and evaluated needs personal trainer to assist them to exercise. (health diagnosis). These variables are This study finds that 82.50% of the measured from various symptoms, disturbed respondents preferred to slip gym rooms for functions, and perceptions of health (Liam et men and women. As many as 60.83% of al. 2017). respondents preferred private gymnasium

Ragilia Indah Lutfiana, Sonny Marsetyo, Pitasari Nastiti and Ernawaty, The Influence Of Clinical... 353 Perceived needs (Subject assessment) Role of health diagnosis on gymnasium needs Green (1980) proposes two behavioral variables that may influence priority needs. There are several steps in analyzing These include predisposing factor andoutside Gosslow's needs (Makmur and Widagdo behavior (enabling factor and reinforcing 2017): The first step is gathering information, factor). The predisposing factors include such as activities offered, who understands knowledge, attitudes, beliefs in health, values, what, who will learn, obstacles, and the perceptions, and demographic factors that influence of certain circumstances. The will influence individual and community information will be useful in determining motivation to take action. goals to be achieved and priority problems to The respondents need indoor and outdoor be resolved. gymnasium concepts, seperate gymnasium rooms for men and women, and private The second step is identifying gaps gymnasium which only can be access by the through the Organizational Elements Model society of acedemicians at Campus C, (OEM). The model explains five elements Universitas Airlangga. Most of those who (Suryana Hasim 2013). The first two elements required gymnasium facilities were female involve input and process in the utilization of students aged 21-30 years. They favored every potential and existing sources, and the sports because they wanted to keep the body other three include products, outputs and healthy and mantain ideal weight. outcomes as the final result of a process. Input components include the present conditions, Evaluated needs (Health diagnosis) for example, finance, time, buildings, teachers, students, needs, problems, goals, Despite perceived needs, enabling and curriculum materials. Additionally, factors include personal skills, group process components involve staff formation, resources, and community resources, education according to competencies, including the availability of health service planning, methods, individual learning, and facilities, health workers, costs, distance, and applicable curriculum. access to transportation. Besides, reinforcing factors support the emergence of health Product components include completion measures and include family factors, friends, of education, skills, knowledge, and attitudes, teachers, regulations, and legislation in the as well as successful competency test. health sector, attitudes, and behavior of health Further, output components involve workers, as well as other factors related to graduation certificates, prerequisite skills, and health providers. licenses. The outcome components are related to the adequacy and contribution of Almost all students had health individuals or groups at present and in the problems. Overweight was the most common future. Using these component analyses, health issue experienced by the students, and gymnasium architects can determine the some also experienced digestive disorders extent to which a gymnasium is useful for the (gastritis). Less than 50% of the students users. These analyses essentially determine checked their health problems to doctors, and gaps between expectations and reality. most of them were recommended to do swimming. The next step is analyzing performance. In the third stage, after the architects understand various information and identifies gaps, they can analyze performance. They learn from formulating new management policies and a better organizational structure,

354 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:348-355 or developing materials and tools. that provides a swimming pool. The Performance analysis includes identification determination of students’ dymnasium needs of teachers, suggestions, school policies, was considered through doctors’ advice for social climate and psychological climate, as well as complete student learning support. swimming activities based on the health The fourth is identifying obstacles. diagnosis. This study summarizes a health Various obstacles may occur due to facility diagnosis playes a role on gymnasium needs time, materials, grouping and composition, philosophy, personnel and organization. of the students at Universitas Airlangga. Besides, constraints also may arise from a Considering high demands on the learning program, for example, teachers, principals, and students themselves. establishment of gymnasium and lots of its Addtionally, philosophy of work, work health benefits, the campus is expected to motivation, and competence may be other build a gymnasium with its required facilities. constraints too.Moreover, other constraints Moreover, further research should study more may occue due to the existing facilities, deeply about factors that affect motivation for including the availability, completeness, and condition of the facilities, and the amount of exercises or sports so that the university may funding and its allocation. consider gymnasium facilities that can facilitate the students’ most favorite sports. Then, the last step is identifying objectives (Makmur and Widagdo 2017). REFERENCE Need assessment is a process of identifying, documenting, and justifying gaps between the Kotler, Armstrong. 2010. Principles current situation and later outcomes based on the priority scale of each need Kaufman Marketing. 17th ed. ed. Marc Oliver (1983). Not all needs are instructionally designed objectives. An architect needs to Opresnik. Northwestern: Global Edition. determine urgents needs more on the top of Liam, Wil et al. 2017. “Perancangan Gym the others. Center Dengan Fasilitas Penunjang Bagi This study reports that nearly half of Pengguna Di Surabaya.” Intra 5(2): the students had a desire to do swimming as 524–30. their doctors recommended to do so. Therefore, the students preferred swimming Makmur, Harbet, and Herry Widagdo. 2017. pool which becomes one of the gymnasium facilities. Most of them required mixed “HEALTHY GYM FAMILY concepts of an indoor and outdoor gymnasium. In carrying out execercises, the (Perencanaan Pendirian Usaha Jasa majority of the students did not need a Fitness Center).” Jurnal Manajemen personal trainer. Finally, more than 80% of STIE Multi Data Palembang: 1–15. the students preferred separate gym rooms for male and female. Muttaqin, Andi, Ifwandi, and Muhammad Jafar. 2016. “Motivasi Member Fitness CONCLUSION Center Dalam Melakukan Latihan It can be concluded that the students at Universitas Airlangga require a gymnasium Kebugaran Jasmani (Studi Kasus Pada Member Wana Gym Banda Aceh Tahun 2015).” Jurnal Ilmiah Mahasiswa Pendidikan Jasmani, Kesehatan dan Rekreasi 2: 100–113. Rinawiyanti, Esti Dwi, Rosita Meitha, Jeremia Januar, and Pratama Putra. 2014. “Studi Segmentasi Berorientasikan Psikografis Dan Behavioral Pada Konsumen Fitness Center Di Surabaya.” International Management di Fachhochschule Nuertingen University 7(1): 25–38.

Ragilia Indah Lutfiana, Sonny Marsetyo, Pitasari Nastiti and Ernawaty, The Influence Of Clinical... 355 Samudin, Esti Yulitriani T, and Adi Sasmito. Suryana Hasim. 2013. Analisis Strategi 2017. “Semarang Sport Centre (Dengan Pemasaran Gym Dan Swimming Pool Pendekatan Konsep Penekanan Hi-Tech Architecture).” Universitas Pandanaran YHI Whellness Hotel Melia Purosani (1): 1–20. Saqurin. 2013. “Tingkat Kebugaran Pada Yogyakarta. Yogyakarta: Universitas Mahasiswa Dengan Olah Raga Negeri Yogyakarta. Taekwondo Di Universitas Airlangga.” Takdir D., Mahmudin, Sudirman. 2008. 1 Fakultas Keperawatan Universitas Kewirausahaan. Wijaya Muhadi Karya : Airlangga: 7. Yogyakarta. Sugiyono. 2011. “Statistik Untuk Penelitian.” Trudeau. 2008. “Kumpulan Makalah : 1–370. Disampaikan Pada Konvensi Nasional Pendidikan Universitas Pendidikan Indonesia.” Jurnal Keolahragaan

RECOMMENDATION OF DIPHTHERIA ANTITOXIN TO DIFFERENT SUSPECTS DURING THE DIPHTHERIA OUTBREAKS,LUMAJANG DISTRICT IN 2018 Munif Arifin Lumajang District Health Office Jalan Jend. S. Parman Number 13 Tel. (0334) 881066, Lumajang, East Java, Indonesia Correspondence Address: Munif Arifin Email: [email protected] ABSTRACT The number of diphtheria suspects in Lumajang district was the second highest in East Java province during the diphtheria outbreaks in 2018. The number of diphtheria cases was more than 500% in 2018 compared to 2017. To give diphtheria antitoxin (DAT), the provincial diphtheria expert team consider various suspects’ characteristics for DAT recommendation as DAT supplies are limited. This case report aimed to explore and describe the relationship between diphtheria suspects’ characteristics, including age, gender, symptoms, immunization status, duration of disease, and contact status with other suspects according to the DAT recommendations from the expert team. This case report was descriptive and used a cross-sectional approach. It was conductedduring the diphtheria outbreaks and involved total samples of all suspects. Based on age, the majority of the suspects (92%)were under 19 years old. Suspects at this age were the target of an outbreak response immunization (ORI) program. Those who were not targetted to receive ORI (aged over 19 years) began to appear in November and mostly in December. The trend of non-ORI targetted age increased after the third round of ORI implementation. According to the report form parents, most suspects (46.7%) had complete immunization status, and only 6.7% of their immunization records were reported on growth chart cards. All suspects with positive diphtheria never had and know routine immunization records. The laboratory tests show only 5% were suspected with positive diphtheria with a cultural type of mitis toxigenic. As many as 32% of the total suspects were recommended for DAT treatment. The use of controlled DAT could save 1,640,000 iU. Keywords: Diphtheria, outbreak response immunization, diphtheria antitoxin. ABSTRAK Jumlah suspek penyakit difteri di Kabupaten Lumajang tertinggi ke dua di Jawa Timur saat Kejadian Luar Biasa (KLB) difteri tahun 2018. Terjadi peningkatan kasus pada tahun 2018 mencapai lebih 500% dibandingkan tahun 2017. Untuk memberikan serum antidifteri pada suspek, Tim Ahli Difteri Provinsi mempertimbangkan berbagai karakteristik suspek untuk rekomendasi serum antidifteri. Rekomendasi ini dilakukan karena keterbatasan persediaan serum antidifteri. Case report bertujuan untuk mengeksplorasi dan mendiskripsikan hubungan karakteristik suspek difteri, meliputi umur, jenis kelamin, gejala, status imunisasi, lama sakit, dan status kontak dengan suspek lain dengan rekomendasi serum antidifteri dari tim ahli. Case report ini menggunakan rancangan diskriptif dan pendekatan potong lintang. Case report ini dilakukan selama KLB difteri dan melibatkan total sampel seluruh suspek. Berdasarkan usia, mayoritas suspek (92%) berusia di bawah 19 tahun. Usia ini merupakan sasaran program imunisasi tanggap kejadian luar biasa. Suspek yang bukan sasaran program imunisasi ini (berumur lebih dari 19 tahun) mulai muncul pada bulan Nopember dan sebagian besar pada bulan Desember. Tren usia suspek yang bukan sasaran ORI meningkat setelah pelaksanaan ORI putaran ke tiga. Sebagian besar suspek (46.7%) mempunyai status imunisasi lengkap berdasarkan informasi dari orang tua, dan hanya 6.7% mempunyai catatan imunisasi pada Kartu Menuju Sehat (KMS). Seluruh suspek dengan positif difteri tidak pernah melakukan dan tidak mengetahui catatan imunisasi rutin tersebut. Uji laboratorium menunjukkan hanya terdapat 5% suspek dengan hasil uji laboratorium positif mitis toksigenik. Jumlah suspek yang direkomendasikan mendapatkan terapi serum antidifteri sebanyak 32%. Penggunaan serum antidifteri yang “terkendali” dapat menghemat 1.640.000 iu serum antidifteri. Kata Kunci: Difteri, imunisasi tanggap kejadian luar biasa, serum antidifteri. INTRODUCTION immunization to suspects. This disease is caused by the gram-positive bacterium Diphtheria is a highly contagious Corynebacterium diphtheria strain of the disease that can be prevented by giving toxin and characterized by inflammation on ©2020 IJPH. License doi: 10.20473/ijph.vl15il.2020.356-368 Received 1 July 2019, received in revised form 10 July 2019, Accepted 17 September 2019, Published online: December 2020

the infected parts, especially the mucous Munif Arifin, Recommendation Aspect of... 357 membranes of the pharynx, larynx, tonsils, quickly. Some signs and symptoms of diphtheria were still unclear, but some nose, and skin. Severe diphtheria can be people who had such obscure symptoms such as painful swallowing, characterized by difficulty in swallowing, pseudomembrane, epistaxis, bull neck, and stridor had been reported as suspects. Fast shortness of breath, stridor, and neck case tracking could give fast prevention measures for the disease transmission, swelling that looks like a bull neck. Death leaving aside the possibility of overdiagnosis (Lumajang District Health usually occurs due to obstruction or Office, 2018). blockage of the airway, damage on the heart According to the standard operating procedure (SOP), suspects found in less muscle, and abnormalities in the central than 24 hours must be reported to the East Java Provincial Health Office in Form Dip nervous system and kidney (Indonesian 1, which contains various suspects’ data, including name, age, address, immunization Ministry of Health, 2017). status, signs and symptoms, and others. This report is used not only as an outbreak The Circular Letter of the Governor epidemiological update but also as considerations for the Diphtheria Expert of East Java Number 460/69/012.4/2018 Team of East Java Province to recommend DAT treatment for the suspects. The expert concerning determination of diphtheria team come from Dr. Soetomo District General Hospital and Universitas Airlangga outbreaks in East Java and the Decree of the The team sent the recommendation along with the suspects’ pseudomembrane photos Regent of Lumajang district Number through WhatsApp chats. 188.45/16/427.12/2018 concerning Not all suspects receive DAT treatment due to the limitations of DAT at diphtheria outbreaks announced that the provincial level. Hence, DAT was distributed by recommendationtreatment diphtheria outbreaks occurred in Lumajang that applied to diphtheria suspects in Lumajang district. Treatment district, as well as other East Java regions. METHODS Outbreaks of infectious diseases, especially This case report used a those that can be prevented by quantitative-descriptive design and a cross-sectional approach during the 2018 immunization become public health diphtheria outbreaks. It sampled all diphtheria suspects in Lumajang district problems because they result in greater and focused on the analysis of DAT treatment recommendations of the risks of morbidity and deaths. The disease provincial diphtheria expert team. The mechanism of DAT recommendation was transmission should be anticipated and done at some stages. First, every diphtheria suspect found in a health prevented quickly and accordingly. During the diphtheria outbreaks, an outbreak response immunization (ORI) program was carried out through the distribution of 3 doses of diphtheria immunization to people aged 1-19 years. This program has also been carried out in regions where such outbreaks occur as stipulated in the Regulation of Indonesian Ministry of Health No. 1501 of 2010 concerning certain types of communicable diseases that need plague and mitigation measures. The number of diphtheria suspects in Lumajang district in 2018 was ranked the second highest in East Java province. In 2017, there were 11 diphtheria suspects and 60 suspects in 2018. The increase between the years was more than 500%. Such increase occurred possibly as the primary healthcare center and hospital surveillance officers did track and report the suspects

358 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 service facility (primary healthcare Letter of Director-General of P2P Number UM.01.05/1/3274/2017 on 21st December center, clinic, or hospital) was reported 2017 concerning about the prevention of diphtheria outbreaks. online through WhatsApp to the East Java Moreover, the East Java Provincial Provincial Health Office. The report Government issued the Letter of East Java consisted of suspects’ pseudomembrane Governor to the Regent/Mayor on 8th January 2017 Number: 460/69/012.4/2018, photos, immunization status, age, gender, regarding determination of diphtheria outbreaks, anticipation of surges and age, symptoms (pseudomembrane, disease transmission, and the implementation of an outbreak response epistaxis, bull neck, and stridor), date of immunization (ORI) program. disease, history of contact with other The immunization program was carried out in regions where the outbreaks suspects, treatment given, or bleeding occurred based on the Regulation of Indonesian Ministry of Health No. 1501 of status during a throat or nasal swab. 2010 concerning certain types of communicable diseases that need plague Second, the provincial diphtheria expert and mitigation measures. This program aims to break the chain of transmission and team provided several possible immediately end the outbreaks and high immunity gaps in infants. Few infants in recommendations based on the report: 1) Lumajang have received complete basic immunization, and this immunization has Negative diphtheria, 2) Erythromycin not equally been distributed. Ideally, further immunization should be given to children at antibiotic treatment, PPC, or mouth rinse, school ages to future outbreaks. and 3) DAT treatment (with its dosage). In the third stage, the epidemiological surveillance officers tracked the suspects and people in close contact with them and collected a specimen collection of the throat and nasal swabs, as well as prophylaxis. Furthermore, the swab results were tested for further diagnosis in the Central Laboratory of Health Laboratory of Surabaya . This case report basically identified the relationship between DAT recommendationtreatmentas an independent variable and dependent The number of diphtheri suspects in Lumajang district in 2018 variables including immunization status, The number of diphtheria suspects in age, gender, symptoms 2018 was 60 suspects spread in 22 primary healthcare centers, except Ranuyoso, (pseudomembranous, epistaxis, bull Pronojiwo, and Penanggal Primary Healthcare Centers. neck, stridor), date of disease, and history Suspects’ characteristics based on of contact with other suspects. domicileThe suspects’ domiciles are presented in Table 1. Meanwhile, to see the significance and degree of the relationship, this case report utilized the bivariate test. Further, multivariate logistic regression was carried out to analyze statistically significant risk factors for DAT Table 1. Frequency Distribution of the Diphtheria Suspects based on recommendation. Domiciles in Lumajang District in 2018. RESULTS During the diphtheria outbreaks, the Puskesmas Total % suspects aged 1-19 years were given 3 doses of diphtheria immunization in February, Rogotrunan 17 27.87 July, and November 2018. This Pasirian 6 9.84 immunization program was according to the Kedungjajang 5 8.20 Sukodono 5 8.20

Munif Arifin, Recommendation Aspect of... 359 Puskesmas Total % Table 2. Distribution of Suspects’ Characteristics based on Age and Candipuro 3 4.92 Gender in Lumajang District in 2018. Jatiroto 3 4.92 Padang 2 3.28 Randuagung 2 3.28 Suspects’ n% Characteristics Tempursari 2 3.28 Age 1 1.7 5 8.3 Tunjung 2 3.28 < 1 year 46 76.7 >1 s/d 2 year 8 13.3 Yosowilangun 2 3.28 >2 s/d 8 year > 8 year 37 60.7 Bades 1 1.64 23 37.7 Gender Gesang 1 1.64 Male Female Bades 1 1.64 Gesang 1 1.64 Gucialit 1 1.64 Klakah 1 1.64 Kunir 1 1.64 Labruk 1 1.64 Pasrujambe 1 1.64 Senduro 1 1.64 The majority of the suspects (76.7%) were aged 2-8 years old. The Sumbersari 1 1.64 lowest age of suspicion is 1 year, the highest is 39 years. Based on gender, most of the Tekung 1 1.64 suspects were male (60.7%), while women were 37.7%. Tempeh 1 1.64 Suspects’ characteristics based on risk Total 60 100 factors for immunization status and history of contact Most of the suspects (28%) lived in This case report presents risk factors the working area of the Rogotrunan for immunization status and history of contact in Table 3. Primary Healthcare Center, but the suspects spread in almost all working areas (88%). Based on monthly trends, diphtheria suspect fluctuations are presented in Graph 1. Table 3. Frequency Distribution of Risk Factors for Immunization Status and History of Contacts with Other Diphtheria Suspects in Lumajang District in 2018. Graph 1. Trends of Diphtheria Suspects in Variables n % Lumajang District in 2018. Immunization 4 6.7 Status 2 46.7 At the beginning of the year from 8 11.7 January to July, the trend of suspects tended to - Complete fall, then rose in July to September, and Growth Chart significantly increased again in December. Cards Table 2 illustrates - Information from parents - Incomplete records

360 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 Variables n % Further symptoms were presented in Table - Do not know 7 15.0 4. 20.0 the cards 9 - Never 1 Table 4. Frequency Distribution of 2 Suspects’ Diphtheria Symptoms complete the cards in Lumajang District in 2018. History of contact - Never Suspect n% - Ever Characteristics Pseudomembranous 5 91.7 - Negative 5 8.3 5 - Positive 00 60 100 Based on immunization status, most Epistaxis 58 96.7 of the suspects (46.7%) had complete - Negative 2 3.3 immunization as their parentas told. Only - Positive 6.7% had complete immunization reported in their growth chart cards.Regarding a Bull neck 41 68.3 history of contact, 55 suspects (91.7%) had - Negative 19 31.7 never been in contact with other suspects, - Positive while 5 others (8.3%) had. Stridor 38 63.3 Suspects’ characteristics based on - Negative 22 36.7 symptoms - Positive Table 4 explains that all suspects Suspect characteristics based on the (100%) were positive pseudomembranous, duration of disease 58 suspects (96.7%) were negative epistaxis, 41 suspects (68.3%) had no Table 5 presents how long the symptoms of bull neck, and 38 suspects suspects suffered from diphtheria before being (63.3%) had no symptoms of stridor. treated in health service facilities. Table 5. Frequency Distribution of the Duration of Disease Experienced by the Diphtheria Suspects in Lumajang District in 2018. Duration of Not Recommended DAT Status Total Disease 30 (77%) treatmentRecommended 39 1-3 days 8 (45%) 9 (23%) 18 4-6 days 3 (100%) 10 (56%) 3 >7 days 41 (68%) 0 (0%) 60 Total 19 (32%) Based on Table 5, most suspects possibility for DAT experienced the disease for 1-3 days and some of them received DAT recommendations. treatmentrecommendations. While suspects with the duration of 4-6 days were given DAT recommendations. The Suspects’ characteristics based on sooner the duration of disease, the less treatment status

Munif Arifin, Recommendation Aspect of... 361 Besides, this case report shows that treatment, while 19 (31.7%) others were 55 suspects (91.7%) were hospitalized, and given DAT treatment. Regarding DAT 5 other suspects (8.3%) received outpatient dose, of 19 suspects given DAT treatment, care. Before being hospitalized, 39 suspects 12 suspects (20%) received a DAT dose of (65%) had been sick for 1-3 days, 18 40,000 Iu, 4 suspects received a DAT dose suspects had suffered from the disease for of 20,000 Iu, 2 suspects had a DAT dose of 4-6 days (30.0%), and 3 suspects had been 60,000 Iu, and 1 suspect received a DAT sick for 7 days (5 %). dose of 80,000 Iu. Table 6. Frequency Distribution of Table 7. Frequency Distribution of DAT Treatment Status of Diphtheria Status in Diphtheria Suspects in Suspects in Lumajang District in Lumajang District in 2018. 2018. Variables n% Variables n% Diphtheria Antitoxin Treatment status 55 91.7 (DAT) - Inpatient 5 8.3 - Outpatient - Not Duration of Disease - 1-3 days recommended 41 68.331.7 - 4-6 days - >7 days - Recommended 19 DAT dose Not recommended 20.OOO IU 41 68.33 39 65.0 40.OOO IU 4 6.67 18 30.0 3 5.0 60.000 IU 12 20.00 80.000 IU 2 3.33 Total 1 1.67 Suspects’ characteristics based on DAT 60 100.00 status DAT given to suspects was In Table 7, this study finds 41 associated with duration of disease prior to suspects (68.3%) were not given DAT health treatment at health service facilities. Table 8. Frequency Distribution of DAT Recommendation and Duration of Disease in Diphtheria Suspects in Lumajang District in 2018. Duration of Not Recommended DAT Status Total Disease treatmentRecommended 1-3 30 9 39 days Count 77% 23% 100% 50% 15% 65% % within % of Total 8 10 18 4-6 44% 56% 100% days Count 13% 17% 30% % within % of Total 3 03 >7 days Count

362 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 Duration of Not Recommended DAT Status Total Disease 100% treatmentRecommended 100% Total % within 5% 5% % of Total 41 0% 60 Count 68% 0% % within 68% 19 100% % of Total 32% 100% 32% Table 9. Frequency Distribution of Laboratory Test Results of Diphtheria Suspects in Lumajang District in 2018. DAT Status Results of laboratory specimen examination Negative Positive Total Graph 2. Percentage of Suspects’ Not 40 1 (2%) 41 Age and DAT Recommendation in Recommended (98%) 2 (10%) (100%) Lumajang District 2018. Recommended 3 (5%) treatment 17 19 Graph 2 shows that the majority of (90%) (100%) DAT recommendations were given to Total suspects aged 2-8 years. However, most 57 60 suspects aged 1-2 years were not (95%) (100%) recommended for DAT. treatment The implementation of outbreak Suspects’ characteristics based on response immunization (ORI) program laboratory test results in 2018 Based on Table 9, there were 3 The outbreak response suspects (5%) with the positive of toxigenic immunization (ORI) in Lumajang district mythic. was conducted in 3 rounds, between February-March, June-July, and November-December 2018. Table 10 shows the recapitulation of ORI coverage in Lumajang district in 2018. Table 10. Coverage of ORI in Lumajang District 2018. Total coverage of 1 to <19 years Age Total target Round 1 Round 2 Round 3 Range Proy Riil Pro Rii Pro Riil Pro Riil Abs y l Abs y (%) Abs yi (%) (% (%) (%) ) (%) 1 S/D < 57.71 59.841 58.47 101 98 58.47 101 98 56.56 98.0 95 5 Years 7 40.771 1 1 30 ≥5-<7 30.09 40.87 136 10 39.80 132 98 39.95 132. 98 Years 9 1 0 5 1 73

Munif Arifin, Recommendation Aspect of... 363 Total target Total coverage of 1 to <19 years Proy Riil Age Round 1 Round 2 Round 3 Range Pro Rii Pro Riil Pro Riil Abs y l Abs y (%) Abs yi (%) (% (%) (%) ) (%) ≥7-<19 185.6 160.91 158.0 85 98 157.6 85 96 156.7 84.4 97 Years 60 9 14 28 34 2 Total 273.4 261.53 256.7 94 98 255.9 94 98 253.2 92.6 97 1-<19 76 1 55 04 48 0 Years Overall, the ORI coverage had reached the especially of the target age of 1 to <5 years. minimum target of 90%. The trends show a The coverage corresponds to the number of decrease in ORI coverage in the third round. diphtheria suspects in Lumajang district as seen in Graph 4. The number of diphtheria suspects decreased while the ORI coverage increased. Meanwhile, Graph 5 shows the coverage of the target age of ORI program. Graph 3. ORI Coverage in Lumajang District in 2018. Graph 5. The Target Age of Diphtheria Suspects for ORI Program in Lumajang District in 2018. The number of non-targetted age for ORI program began to emerge in November, and the highest one was found in December. The calculation of the association between routine immunization and suspects’ characteristics is available in Graph 6. Graph 4. ORI Coverage and the Number of Diphtheria Suspects in Lumajang District in 2018. Graph 3 illustrates the trend in round 3 was the most decreasing ORI coverage,

364 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 Graph 6. Association between Diphtheria there were no deaths as 100% suspects were Suspects and Routine treated less than 24 hours according to the Immunization Coverage in standard. Lumajang District in 2018. Epidemiological aspects of diphtheria Graph 6 illustrates only Rogotrunan suspicion Primary Healthcare Center had below 95% of routine immunization coverage, but it Most of the suspects (28%) lived in had the highest number of suspects. the working areas of Rogotrunan Primary Whereas Tekung Primary Healthcare Healthcare Center. While there were eight Center had lower coverage and a low suspects from the Pasirian Primary Healthcare number of suspects. Center, five others from Kedungjajang Primary Healthcare Center, five others from DISCUSSION Sukodono Primary Healthcare Center, 3 suspects from Candipuro Primary Healthcare This study reports an increase in Center, and 3 suspects from Jatiroto Primary sdiphtheria suspects occurred during the Healthcare Center. While there was only one diphtheria outbreaks in Lumajang district. suspect in each of other primary healthcare In 2017, there were 11 diphtheria suspects, centers. The other three primary healthcare while in 2018 there were 60 suspects. Based centers (Pronojiwo, Penanggal, and on the results of laboratory tests, 3 suspects Ranuyoso) had no diphtheria suspects in were positive toxigenic mythic. The 2018. number of diphtheria suspects in 2018 was higher than in 2017. In 2018, the suspects Some primary healthcare centers with were found in almost all regions (88% the high number of diphtheria suspects were working areas of primary healthcare located in urban areas (Rogotrunan, centers). Sukodono, and Kedungjajang Primary Healthcare Centers), or in areas with high According to the standard operating population density (Pasirian and Jatiroto procedure (SOP) and diphtheria prevention Primary Healthcare Centers). Whereas no technical guidelines, diphtheria situation diphtheria suspects wre found in highland would be considered an outbreak if one areas (Pronojiwo, Penanggal, and Ranuyoso). suspect was found without waiting for Further study is required to examine the laboratory test results. Immediate relationship between topographic and countermeasures were done, such as taking environmental aspects and diphtheria all specimens of the throat and nasal swabs. suspicion. The specimens were then investigated in the Central Laboratory of Health Laboratory Suspects’ characteristics based on age (BBLK) of Surabaya. During the and gender countermeasures, treatments were given and did have the success rate of 100%, and After the first ORI round and the second ORI round, the number of diphtheria suspects fluctuated. In 2018, only 5 suspected people were aged over 19 years (non-targetted age for ORI), 4 suspects were found in December, and 1 suspect was found in November. This shows that the shifting trend of non-targetted suspects occurred after the implementation of the third ORI round. From January to October 2018, there were no suspected people aged 19 years in the first and second ORI rounds. After these

roundsa, suspects aged over 19 years old were Munif Arifin, Recommendation Aspect of... 365 discovered in November (1 suspect) and December (4 suspects). It can be assumed that result in a negative Schick test result of after of the first and second ORI rounds, the 83.84% and 3 times immunizations showed suspects receiving ORI had stronger a perfect negative Schick test result. It immunity, and the non-targetted suspects’ age means the more complete the for ORI had replaced the targeted suspects’ immunization, the better the immunization age. The chi-square test shows a significant status. relationship between ORI and the shifting age of diphtheria suspects with a α value of 0.004. Moreover, this study reports 24% of the suspects had never been immunized, the Suspects’ characteristics based on risk majority of suspects (43%) had complete factors for immunization status and history immunization status according to of contact information from their parents (no documented evidence). Whereas the Regarding history of contact with percentage of suspects with complete other suspects, , 4 of 5 suspects (80%) who immunization status who had growth chart ever had contact with other suspects were cards was only 7%. This study further aged 5 years, and 1 suspect with similar reveals nearly half of the suspects without contant was 3 years old. It suggests that immunization records were aged >10 years. childhood or younger ages are the state of While all suspects who had immunization playtime which greatly leads children to records were less than 5 years old contract diphtheria. (toddlers). From these findings, immunization records and reporting system The majority of the suspects (75%) are required. were over 5 years old, and only 25% of them were under 5 years old. The trend of Furthermore, this study reports most diphtheria suspicion was increasing in of the suspects had problems with adulthood. Given the target age for ORI, the immunization due to incomplete majority (92%) were less than 19 years old immunization, undetected immunization and thus not targetted to receive ORI. Most status, and absence of immunization. These parents of the suspects did not know their findings are relevant with other studies child’s immunization status, while other which find the relationship between said their children had never been diphtheria and immunization status. immunized. Only 6.7% of the suspects had According to Utami (2010), incomplete documentary evidence such as growth chart immunization status could affect diphtheria cards. It suggests that most suspects had transmission and put people at 3.9 times incomplete immunization, thus increasing greater risks for contracting diphtheria the risk of susceptibility to diphtheria. The compared with complete immunization use of antibody titers tend to be higher status. Further, Widoyono (2011) explains because of better immunization intervals. the mortality rate in children without Children should be immunized with immunization is four times greater than diphtheria (in 0-12 months) and with children who are immunized. booster (in 18 to 24 months) and BIAS (at grade 1 and 2 of elementary schools). Suspects’ characteristics based on symptoms These results are consistent with Lubis's (2005) study, which states that According to its etiology, diphtheria is children who received DPT immunization a very contagious disease caused by once showed a negative Schick test result of Corynebacterium diphtheria. It causes 72.73%. Further, twice immunization could symptoms and signs such as fever at 38ºC, bleeding and painful swallowing due to grayish-white pseudomembranes or

366 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 membranes in the throat, enlargement of the sSuspects’ characteristics based on DAT neck lymph nodes, and swollen soft neck treatment and results of laboratory tests tissue so-called the bull neck. Some other symptoms also inclde shortness of breath and Based on the results of laboratory snoring sound. tests, of the 60 suspects, there were 3 suspects with positive mythic toxicity. One In 2018, the main reason for DAT of them was 16 years old, and two others treatmentwas made by the expert team’s were 22 years old. Two suspects (67%) recommendation due to pseudomembranous received DAT, and one suspect (33%) did symptoms. All suspects with these symptoms not receive DAT recommendation. received DAT treatment. While other KA, 16 years old, Pasirian, never symptoms included epistaxis (3.3%), bull immunized, received ORI in the first round; neck (31.7%), and stridor (36.7%). WK, 22 years old, Pasirian, never immunized, received ORI in the first round; Suspects’ characteristics based on DAT AN, 22 years old, Kunir, never immunized, status did not receive ORI. Doctors diagnosed diphtheria based This study reports most adult on symptoms and clinical condition. suspects were positive diphtheria. Diphtheria treatment begins by distributing Immunizationwere given to these suspects DAT and antibiotics to the suspects without by considering their body immune. Besides, laboratory results or swab results. DAT there were three suspects that had never had dose ranging between 20,000-100,000 IU routine immunization. Kartono's research was determined empirically based on (2007) finds that the main factor that causes disease severity and duration of disease, and diphtheria was incomplete DPT/DT suspects’ weight ( Indonesian Ministry of immunization which contributed to 46,403 Health, 2017). times greater risk of diphtheria in children. The number of suspects Two of three suspects were still recommended for DAT treatment was 19 students. This suggests that diphtheria people (32%), who received 760,000 IU of transmission was associated with DAT dose. The majority (63%) environmental aspects. recommended for DAT received 40,000 IU of DAT dose. The total number of DAT Outbreak response immunization during doses was 760,00 IU or on average 4 vials diphtheria outbreaks in Lumajang (@ 10,000 IU). The use of \"controlled\" district in 2018 DAT ould save 1,640,000 IU of DAT dose. If converted to 41 suspects, it would be The Letter of East Java Governor formulates as 41 suspects x 4 vials = 164 vials x Rp. 2,200,000 = IDR 360,800,000. assigned the Regent/Mayor on 8th January Based on response of actions, this 2017 Number: 460/69/012.4/2018 to study finds the faster the suspect was referred to a health service facility (a immedeiately announce diphtheria primary healthcare center and hospital), the less possible they would receive ADT outbreaks. Such immediate announcement treatment. There were 23% suspects with disease duration of 1-3 days (before being aimed to anticipate spikes and disease referred to a health service facility) who received DAT. Most suspects (56%) had transmission. During the outbreaks, an disease duration of 4-6 days. The success rate of treatment was 100% (no deaths), and outbreak response immunization (ORI) all suspects were treated in less than 24 hours according to the standard. program was carried out by referring to the Decree of the Regent of Lumajang Number: 188.45/16/427.12/2018 concerning diphtheria outbreaks and outbreak response immunization (ORI) program in Lumajang district. The district had achieved the minimum target of ORI coverage at 90%.

Munif Arifin, Recommendation Aspect of... 367 However, several primary healthcare Kabupaen Lumajang Tahun 2018, centers did not reach the minimum target. The lowest ORI coverage occurred to 12 Dinkes Lumajang primary healthcare cetners in the first ORI round. Regulation of the Minister of Health Nomor The ORI coverage was not directly 1501 tahun 2010 tentang Jenis proportional to the number of suspects in each working area. Penyakit Menular Tertentu yang Based on the findings, the number Dapat Menimbulkan Wabah dan of suspects would be more dominantly influenced by the population density Upaya Penanggulangan. compared to the ORI coverage. Diseases transmit easily through direct contact in Indonesian Ministry of Health, 2017. high population densities such as urban areas (Notoatmojo, 2007; Achmadi, 2005). Pedoman Pencegahan dan CONCLUSION Pengendalian Difteri, Direktorat The case report concludes during Surveilans dan Karantina Kesehatan the diphtheria outbreaks in 2018, there were 60 suspects who were mostly 19 years old Direktorat Pencegahan dan and became the target for ORI treatment. Only few suspected people had positive Pengendalian Penyakit toxic oxygenic categories. All positive suspects had no routine immunization Decree of the Regent of Lumajang Nomor records. The shift to non-targetted age for ORI treatment increased after the third 188.45/ 16/427.12 /2018 tentang round. Besides, the treatment success rate was perfect and resulted in zero deaths. keadaan kejadian luar biasa difteri There were 19 suspects (32%) who received DAT recommendation with 760,000 IU of (KLB difteri) DAT dose. Furthermore, the use of \"controlled\" DAT could save 1,640,000 IU. Decree of the Regent of Lumajang Nomor : Immunization records and report 188.45/ 17/427.12 /2018 Tentang must always be improved, for example through growth chart books, maternal and Pokja Out Break Response child health books, and infant and toddler cohorts. Besides, the provincial government Immunization (ORI) Difteri Kab. should supply more DAT stocks to reinfore response towards diphtheri treatment. Lumajang REFERENCE Kartono B, Purwana, dan Djaja. 2008. Lumajang District Health Office, 2018, Hubungan Lingkungan Rumah Laporan Kejadian Luar Biasa (KLB) Difteri dan Outbrek dengan Kejadian Luar Biasa (KLB) Response Immunization (ORI) difteri di Kabupaten Tasikmalaya (2005–2006) dan Garut Januari 2007 Jawa Barat. https://doi.org/10.21109/kesmas.v2 i5.250 Lubis, B. 2005. Penelitian Status Imunisasi Terhadap Penyakit Difteri Dengan Schick Test pada Murid Sekolah Taman Kanak-kanak di Kotamadya Medan. e-Journal USU Repository. SE Gubernur Jatim kepada Bupati/Walikota, Nomor 460/69/012.4/2018 tanggal 8 Januari 2018 tentang Penetapan Situasi KLB Difteri di Jatim Notoatmodjo, S. 2007. Promosi Kesehatan dan Ilmu Perilaku. Jakarta : Rineka Cipta Utami, A.W., (2010). Faktor yang mempengaruhi kejadian penularan difteri di Kota Blitar Propinsi Jawa Timur, tesis. Fakultas Kesehatan Masyarakat Universita

368 The Indonesian Journal of Public Health, Vol 15, No 3 December 2020:356-368 Airlangga,Program Studi Ilmu Kesehatan Masyarakat.