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FIELD STUDY REPORT GROUP 1
Johanna List Sinaro Bun
Tianshi Yu Ajib Diptyanusa
Hay Mar Su Lwin Abdulrahman Ahmed M.
Chantasari Charoenkongsakul
Supervisors: Assoc. Prof. Dorn Watthanakulpanich, Asst. Prof. Supaluk Popruk, Supervisors: Assoc. Prof. Dorn Watthanakulpanich, Asst. Prof. Supaluk Popruk, Asst. Prof. Rutcharin Potiwat
INTRO
FIELD STUDY DETAILS
! Location: Suan Pueng, Ratchaburi Province. Ratchaburi is one of the several provinces that outline Thailand with its neighboring nation, Myanmar. Further into the province is Suan Pueng District that particularly delineates the Thai-Myanmar border.
! Date: June 27-30, 2017
! Topic: Field work for parasite and vector survey in the community.
THE VENUE
! Rajanagarindra Tropical Disease International Center (RTIC).
! RTIC is situated at the Suan Pueng District, Ratchaburi Province.
! The RTIC is located at the southern part of Suan Pueng, where majority of the people who live around are Karen hill-tribe.
http://www.tm.mahidol.ac.th/rtic/?q=node/1
THE ACTIVITIES
1. Stool examination
2. Physical examination and blood sample collection
3. Blood film examination
4. Aedes larval survey
5. Rodent trapping and collection
6. Ectoparasite examination
STOOL EXAMINATION
28 June 2017
STOOL EXAMINATION
SUMMARY
! Stool samples examined: 24 samples
! Techniques: direct smear (NS and iodine preparation) and Kato thick smear
! Stool samples with positive pathogenic findings: 12 samples
! Total number of patients treated: 12 patients
STOOL EXAMINATION FINDINGS
No. Direct Smear Kato Thick Smear1 E.coli cyst, E.nana cyst Not found2 Not found Not found3 Not found Not found4 Not found Not found5 Giardia duodenalis cyst, Iodamoeba butschlii cyst Not found6 Not found Not found7 Not found Not found8 E.coli cyst, E.nana cyst Fertilized Ascaris lumbricoides egg9 E.coli cyst Opisthorchis viverrini-like egg
10 Unfertilized Ascaris lumbricoides egg Unfertilized Ascaris lumbricoides egg11 Fertilized & decorticated Ascaris lumbricoides egg, hookworm egg Fertilized Ascaris lumbricoides egg12 Not found Not found13 Fertilized Ascaris lumbricoides egg Fertilized & unfertilized Ascaris lumbricoides egg14 Hookworm egg Not found15 Unfertilized Ascaris lumbricoides egg, hookworm egg Unfertilized Ascaris lumbricoides egg, Trichuris trichiura egg16 Not found Not found17 E.coli cyst, Iodamoeba butschlii cyst, E.histolytica-like cyst Not found18 Not found Not found19 Giardia duodenalis cyst Not found20 E.nana cyst Not found21 E.nana cyst Not found22 Not found Not found23 E.coli cyst, E.nana cyst, E.histolytica-like cyst Not found24 E.coli cyst, Iodamoeba butschlii cyst, Giardia duodenalis cyst Not found
MICROSCOPIC FINDINGS
Entamoeba coli cyst Entamoeba histolytica-like cyst
MICROSCOPIC FINDINGS
Iodamoeba butschlii cyst Giardia duodenalis cyst
MICROSCOPIC FINDINGS
Endolimax nana cyst Trichuris trichiura egg
MICROSCOPIC FINDINGS
Hookworm egg Ascaris lumbricoides decorticated egg
MICROSCOPIC FINDINGS
Opisthorchis-viverrini-like egg
TREATMENT
Pathogenic Findings on Microscopic Examination Disease Treatment Remarks
Fertilized Ascaris lumbricoides egg Ascariasis Albendazole 400mg SD N/A
Unfertilized Ascaris lumbricoides egg Ascariasis Albendazole 400mg SD N/A
Fertilized & unfertilized Ascaris lumbricoides egg
Ascariasis Albendazole 400mg SD N/A
Fertilized & decorticated Ascaris lumbricoides egg, hookworm egg
Ascariasis + hookworm infection Albendazole 1x400mg for 3 days N/A
Unfertilized Ascaris lumbricoides egg, Trichuris trichiura egg, hookworm egg
Ascariasis + Trichuriasis + hookworm infection
Albendazole 1x400mg for 3 days N/A
Hookworm egg Hookworm infection Albendazole 1x400mg for 3 days N/A
Giardia duodenalis cyst Giardiasis Metronidazole 3x500mg for 7 days N/A
Giardia duodenalis cyst Giardiasis Metronidazole 3x500mg for 7 days N/A
Giardia duodenalis cyst Giardiasis Metronidazole 3x500mg for 7 days N/A
E.histolytica-like cyst Suspected amebiasis Metronidazole 3x500mg for 7 days Diarrheic stool
E.histolytica-like cyst Suspected amebiasis Metronidazole 3x500mg for 7 days N/A
Opisthorchis viverrini-like egg Suspected Opisthorchiasis Praziquantel 600mg SD N/A
PHYSICAL EXAMINATION
29 June 2017
BRIEFING AND SETTING UP
AREA MAPPING AND PATIENT FLOW
PATIENT REPORT FORMPATIENT CARD
Name :Sex :Age :
Ethnicity :Occupation :Marital status : N / Y
Family members: Pregnancy status:Body weight/height: kg / cm!
Chief complaint:Present medical history:
Past medical history:!! Hypertension! Diabetes! Malaria! Allergy, specify . . . . . . . . .
! Vaccination, specify . . . . .! Surgery, specify . . . . . . . .! Smoking, . . . . packs/day! Alcohol drinking, . . . . . . . .
! OBGYN . . . . . . . . . . . . .! Others, specify . . . . . . . .!
Physical Examination:General appearance: !Fully conscious !Looks weak !Pallor !Cyanosis !Icteric
- BP: / mmHg - Pulse: x/min- RR: x/min - Temp: oC
HEENT : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lymph node : . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Heart : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lungs : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Abdomen : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Extremities : !edema . . . . . . . . . . . . . . . . . . . . .
Integument : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Others : . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Laboratory Investigations:- Direct smear : . . . . . . . . . . . . . . . . . . . . . . . . . . . . .- Kato Thick smear : . . . . . . . . . . . . . . . . . . . . . . . . . . . . .- Thin blood film : . . . . . . . . . . . . . . . . . . . . . . . . . . . . .- Thick blood film : . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Provisional Diagnosis : . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Treatment : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No.
PHYSICAL EXAMINATION
SUMMARY
! Location: Hwaipha daycare center common grounds
! Time: 9 a.m. - 11 a.m.
! Total number of patients: 39 patients
! Total number of blood samples collected: 23 samples
! Total number of positive blood sample findings: 1 sample
PATIENT DEMOGRAPHIC DATA: SEX
Sex Number Proportion (%)
Male 16 41
Female 23 59
PATIENT DEMOGRAPHIC DATA: AGE (YEARS)
Age (years) Number Proportion
(%)
<1 3 8
1-5 5 13
5-10 1 3
11-20 0 0
21-30 9 23
31-40 5 13
41-50 6 15
51-60 6 15
61-70 4 10
PATIENT DEMOGRAPHIC DATA: ETHNICITY
Ethnicity Number Proportion (%)
Karen 29 74
Thai 10 26
PATIENT DEMOGRAPHIC DATA: OCCUPATION
Occupation Number Proportion (%)
Farmer 9 30
House worker 2 7
General worker 13 43
Soldier 1 3
Unemployed 5 17
PATIENT DEMOGRAPHIC DATA: CHIEF COMPLAINT
Chief Complaint Number Proportion (%)
Acute fever (<7d) 7 18
Respiratory symptoms (cough, runny nose)
3 8
GI symptoms (abd. pain, N/V, diarrhea)
6 15
Muscle pain 9 23
Headache 7 18
Skin rash 4 10
Others (trauma, ulcers) 3 8
PATIENT DEMOGRAPHIC DATA: PAST HISTORY OF MALARIA
History of Malaria Number Proportion
(%)
Positive 13 33
Negative 26 67
DEMOGRAPHIC DATA: PAST HISTORY OF MALARIA
CLOSING REMARKS
BLOOD FILM STAINING
BLOOD FILM EXAMINATION
PATIENT DEMOGRAPHIC DATA: BLOOD EXAMINATION FINDINGS
Parasite Findings Number Proportion
(%)
Positive 1 4
Negative 22 96
BLOOD EXAMINATION FINDINGS
Thick film Thin film
INTERESTING CASE
! Thai male, 23 y.o., soldier
! Acute fever with chills since 26 June 2017
! Came to malaria clinic on 27 June 2017, diagnosed without delay as vivax malaria, treated with chloroquine and primaquine
! No abnormal findings on physical examination
! Degree of parasitemia on day 3 of treatment was 0.24%
AEDESLARVAL SURVEY
29 June 2017
AEDES LARVAL SURVEY
AEDES LARVAL SURVEY
! General purposes of surveillance activities are to:
! Determine the key containers in the domestic environments so that larval source reduction by community participation may be carried out through health education.
! Pinpoint high-risk areas, especially those with high vector density, by plotting vector distribution and numbers of DHF cases on maps. These areas serve as priority areas for control during normal conditions especially during epidemics.
! Determine seasonal population fluctuations for special emphasis on control and alertness during peak vector periods.
! Monitor the impact of vector control interventions including community participation and insecticidal space spraying on vector population.
! Recognize significant changes in vector density, distribution, insecticide susceptibility and vectorial capacity to plan control strategy.
WHO Guidelines for dengue surveillance and control. 2nd edition. 2003. http://www.wpro.who.int/mvp/documents/docs/Guidelines_for_dengue_surveillance_edition2.pdf
HOUSE #1
HOUSE #2
HOUSE #3
HOUSE #4
HOUSE #5
HOUSE #6
HOUSE #7
AEDES LARVAL SURVEY RESULTSContainer Type
House Number
1 2 3 4 5 6 7
Drinking waterNo. of surveys - - - - - - 2
No. of positive - - - - - - 0
Bath and toiletNo. of surveys - - 2 1 - 1 1
No. of positive - - 2 1 - 0 0
Utilized waterNo. of surveys - - - 1 - 3 -
No. of positive - - - 1 - 1 -
Non-utilized waterNo. of surveys 1 - - 1 - - -
No. of positive 1 - - 0 - - -
Storage waterNo. of surveys 3 2 1 - 2 2 3
No. of positive 1 0 0 - 1 0 2
Pet feedNo. of surveys 1 2 - - - - -
No. of positive 0 0 - - - - -
TyreNo. of surveys - - - - - 1 -
No. of positive - - - - - 0 -
Lid/bottom up containerNo. of surveys - - - 1 - - -
No. of positive - - - 0 - - -
Discarded containersNo. of surveys - 1 - 1 - - -
No. of positive - 1 - 0 - - -
Drainage/gutterNo. of surveys - - - - - 1 -
No. of positive - - - - - 0 -
Total 5 5 3 5 2 8 6 34
WATER CONTAINER DISTRIBUTION
Location Number Proportion (%)
Outdoor 25 74
Indoor 9 26
TYPE OF WATER CONTAINERS
Water Containers Outdoor Indoor Total Positive % Remarks
Drinking water 2 0 2 0 0
Bath and toilet 0 5 5 3 60
Utilized water 4 0 4 2 50
Non-utilized water 1 1 2 1 50 Outdoor (1)
Storage water 11 2 13 4 31 Outdoor (2); indoor (2)
Pet feed 3 0 3 0 0
Tyre 1 0 1 0 0
Lid/bottom up container 0 1 1 0 0
Discarded containers 2 0 2 1 50
Drainage/gutter 1 0 1 0 0
Total 25 9 34 11Positive outdoor: 6 Positive indoor: 5
WATER CONTAINER WITH LARVAE
Location of Water Container Number Positive %
Outdoor 25 6 24
Indoor 9 5 56
0
5
10
15
20
Positive Negative
19
6
Outdoor
0
1
2
3
4
5
Positive Negative
45
Indoor
SUMMARY
! Location: houses around the Hwaipha daycare center
! Total number of houses surveyed: 7 houses
! Total number of containers surveyed: 34
! Total number of outdoor containers: 25
! Total number of positive outdoor containers: 6
! Total number of indoor containers: 9
! Total number of positive indoor containers: 5
! Total number of positive water containers: 11
AEDES DENSITY INDICES
WHO Guidelines for dengue surveillance and control. 2nd edition. 2003. http://www.wpro.who.int/mvp/documents/docs/Guidelines_for_dengue_surveillance_edition2.pdf
DATA ANALYSIS
! High risk for dengue transmission?
Total number of surveyed houses 7
Total number of houses positive for larvae 7
Total number of houses positive for pupae 3
Total number of surveyed containers 34
Total number of positive containers 11
House Index (HI) (%) 100
Container Index (CI) (%) 32.35
Breteau Index (BI) 157.1
RESULTS INTERPRETATION
! BI and HI are commonly used for the determination of priority areas for control measures.
! Generally, HI >5% and/or BI >20 is an indication that the locality is high risk for dengue transmission.
WHO Guidelines for dengue surveillance and control. 2nd edition. 2003. http://www.wpro.who.int/mvp/documents/docs/Guidelines_for_dengue_surveillance_edition2.pdf
RODENT TRAPPING
AND COLLECTION
29-30 June 2017
SUMMARY
! Location: Hwaipha daycare center: kitchen and surrounding area
! Number of rodent traps installed: 7
! Number of positive rodent traps: 2
RODENT TRAP INSTALLATION
RODENT TRAP INSTALLATION
RODENT TRAP COLLECTION
ECTO-PARASITE
EXAMINATION30 June 2017
SUMMARY
! Indirect examination using samples acquired from trapped rodents
! Direct examination using flagging and dragging methods
INDIRECT ECTOPARASITE EXAMINATION
! Using rodent trapped in the sta! traps around RTIC
! Rodent species of Rattus rattus
INDIRECT ECTOPARASITE EXAMINATION
INDIRECT ECTOPARASITE EXAMINATION
MICROSCOPIC FINDINGS
Mites found: 30
MICROSCOPIC FINDINGS
DIRECT ECTOPARASITE SURVEY
DIRECT ECTOPARASITE SURVEY
! During the direct ectoparasite survey, our group found several ectoparasites from dragging and flagging method.
! We performed flagging and dragging on the pavement and on the bushes at the forest edge located behind the RTIC venue during the day (around 11 a.m.).
! We were not able to identify the ectoparasites due to limited time.
OVERALL SUMMARY
FIELD STUDY OVERALL SUMMARY
1. Stool examination: total 24 samples, among which 12 were found positive for parasites and were treated accordingly.
2. Physical examination and blood film examination: total 39 patients; one interesting case with Plasmodium vivax found on blood film examination.
3. Aedes larval survey: the surveyed area is categorized as high risk area for dengue transmission.
4. Rodent trapping and collection: 2 out of 7 traps were positive.
5. Ectoparasite examination: 30 mites were found from one trapped rodent.
DIFFICULTIES DURING ACTIVITIES
1. Stool examination: the direct smears dried very quickly; took too much time to examine samples.
2. Physical examination: doctor-patient communication (language barrier); student role rotation.
3. Blood film examination: took too much time to examine samples.
4. Aedes larval survey: identify clearly the purpose of water containers, especially those that were located outdoor.
5. Rodent trapping and collection: no significant issues encountered.
6. Ectoparasite examination: identification of ectoparasites.
SUGGESTIONS
1. Stool examination: direct smear examination should be performed soon after the smear is ready; students need to take note on macroscopic appearance of stool samples; students need to practice more to improve microscopic examination skills.
2. Physical examination: time management, redistribution of students’ role.
3. Blood film examination: students need to practice more to improve microscopic examination skills.
4. Aedes larval survey: simplify the classification of types of water containers.
5. Ectoparasite examination: collect the suspected ectoparasites with little sheets of paper to collect more samples in indirect examination.
LEARNING EXPERIENCES
! Improve knowledge about health system, especially local primary medical services and referral system as well.
! Being able to work and experience providing health services to community in real setting.
! Being able to plan and experience a group work, especially during working in the community.
! Being able to apply previously learned knowledge from the classes into the real setting.
! Strengthening the bond among students and sta!.
! Being able to learn about other culture.
Questions?
ACKNOWLEDGEMENT
1. Assoc. Prof. Dorn Watthanakulpanich, Asst. Prof. Supaluk Popruk, Asst. Prof. Rutcharin Potiwat.
2. Laboratory technicians and all supporting sta! involved in the field study.
3. Local government, o"cers and community.
Thank you!