Friday, July 16, 2010

End of DHO Sik posting

Today, we will not be going to DHO Sik again. Our posting has ended yesterday, now what we have to do is to revise what we has learned in this 2 weeks to prepare for our coming assessment in community medicine.

Thanks to all my group mates especially those who has helped to update this blog daily.

Last day (DAY 10) -Part 2 KPAS

In the afternoon, Mr. Azmir, Environmental Health Assistant Officer came and took our class. He did not give the lecture, instead, he gave us a practical- that is having health assessment in Hospital Sik.

3 of us, Dennis, Zheng Hao and me were briefed on the pointed to be asked and assessed the environmental health in the Hospital Sik. At 3pm, we departed to the Sik Hospital. We went the the Unit Pentadbiran to get the permission from Dr. Haji Sohhimi. 3 of us were divided to assess different place:
a. Dennis: Medical Male Patient Ward 1
b. Jun Sian: X ray lab
c. Zheng Hao: followed Mr. Azmir.

Details of the Environmental Health Asssessment Form:

Later on, we had a discussion regarding to the place that we had assessed. They had already done the assessment. We just compared our result with the result done by Mr. Azmir. About 4pm, the discussion was finished.
That is the end of the Sik DHO Posting. The first day first place we went to assembly was Hospital Sik. The last day last section also end in the Hospital. Is it so coincident?

Thursday, July 15, 2010

Day 10 - The End of Journey : BAKAS (Part 1)

Today, we have the BAKAS activity in the morning section. Mr. Hoslan, PPKP who takes in charge of the BAKAS system in Sik District gave us a short briefing on BAKAS.

Mr. Roslan

Organization Chart of CDC in Sik DHO

Organization Chart of BAKAS In Sik DHO

To improve the Hygiene and Health level of local citizens and to reduce the communicable disease via encouragement of environmental hygiene and health, usage of hygienic and safety water, and use the toilet which is hygienic.

BAKAS programme covers the Environmental and Water Health activities. BAKAS units in Sik District is led vt a PPKP U29 and assisted by a PKAK (Pembantu Kesihatan Awam Kanan) U22 and 3 PKA (Pembantu Kesihatan Awam) U17. Each PKA is helped by a PRA R1 (pembantu rendah am) and a Driver (pemandu) R3. PKA is responsible to implement the BAKAS programme in a sub-district respectively - 2 person in PKD Sik is responsible on Sik and Teloi sub-districts and another 2 person PKA will be placed in KK Gulau and Jeniang to in charge of BAKAS in Sok and Jeneri sub-district. PPKP BAKAS is responsible to Distric Health Officer (Dr. Ishak) through PPKP Kanan in BAKAS activities planning and implementation in each district.

Main Activities Done by BAKAS are:

1.Supply water with Sanitary Latrine (tandas Curah Sempurna) or replacement of Sanitary Latrine
2.Supply water with polypipe and fitting to connect with the water supply from JKR / KKM.
3. Construct Sanitary Well) ( Hand Pump)
4. Construct Sanitary Well) ( connect to the houses)
5. Gravity Feed System
6. Sistem Tadahan Air Hujan
7. Sistem Perlupusan Air Limbah (SPAL)
8. Sistem perlupusan Sisa Pepejal (SPSP) or Sewage & Solid Waste Disposal.

Hand Pump

After that, we were brought by Mr. Azmi, PKAK to in charge of BAKAS in Sik sub-district to Kampung Tanjung Bilik. Here, we were shown the Sanitary Latrine and hand pump.

We reach at Kampung Tanjung Bilik - Encik Yusof house, who is having Sanitary Latrine system and Sanitary Well ( Hand Pump).

Mr. Azmi told us that most of the time, the villager will use the hand pump system to get the water. The hand pump was constructed 15 years ago. It is 100 feet depth. However, occasionally, they will use the water supplied byJKR(air).

A. Mr. Azmi demonstrated how to use the hand pump.
B. Details of the Hand pump

Water from the Sanitary Well ( Hand Pump). It is untreated water but safe to use to drink(if boiling).

Next, we went to visit the Sanitary Latrine sytem (toilet). Ministry of Health will supply the material to construct the Sanitary Latrine. It is 3 feets depth. The cost is about RM 900 (current price), and it is constructed by the villager because they are pro in this career. In the toilet, it does not contain any water flush, waste product will directly stored in the cylinder tank. The tank is able to store the waste product for about 10 years. After that, another tank would be built.

About 9.40am, we departed to another village which is deep into the Kampung Tanjung Bilik. Victor car followed PKA(K), our car (Pala -driver, me, Dennis and Loh) were unable to follow them because they led the road first, there is some difficulty to reverse the car in the Kampung Tanjung Bilik. Unfortunately, Pala's car hit the tree. Thanks god! The car is still 'safe'. Haha....
When we started to follow them, we had lost them in our eyes sight. We kept on asking people, most of them do not know where it is. Some more there is no network coverage. Thanks god again! we had met a kindly villager told us the road to meet them. Finally, we saw Mr. Azmi's motorbike. He continued lead us to the village. Otherwise, we will start our own journey! AND having our own Gravity Feed System. haha.

Gravity Feed System
Next village is Kampung Chakor Topo. My members - Victor, Tharshinii and Fidelia were waiting us right there. Later on, on of the villager, Encik Hashim brought us to the Gravity Feed System. It is deep to the hill. Along the path, some of my member discussed with the PKA and villager. What he discussed, i am not sure about it. The journey takes about 30mins to reach the GFS (Gravity Feed System).

The journey is begun.

Wow, our Victor was talking with Mr. Azmi. Here is the path that we took.

Our Penghulu / leader: Zheng Hao.

It is not Gravity Feed System! It is just the water from the hill.

Here is the pipe that connect to the village. (Details explained subsequently)

Now, we had reached the Gravity Feed System. Unfortunately, it wasn't the GFS what we have seen in the picture from previous batch seniors , the wall or wire fence of the dam was destroyed by the high pressure of water during heavy rain (as picture above). Before it was destroyed, according to Mr. Azmi, the wall / barrier is made by the stone surrounded by the wire fence.(like water in the pond)

Victor was taking another path that we could not get through. He managed to pass all the obstacle and reach there. Thanks god. He succeed!

According to Mr. Azmi, there are 2 pipe systems that supply the village. One is Black Pipe (as picture above: 1- Overview, 2 - magnify version). Another one is Black pipe with white line . Black pipe supplies the village for house usage. Whereas the another one is for filling the water into the artificial fish pond (described later). During raining day, the water from the hill would be very dirty or turbid. They will not use the water directly from the pipe due to turbidity during that time. Instead, each house contain a storage tank that store the clean water as a 'standby'.Therefore, now is the time to use it. However,about 30 mins after rain has stopped, the water will regain its clarity.

After 20 minutes, we started going back. On the way, Zheng Hao and me were discussing with the villager, Encik. Hashim about the Gravity Feed System. He told us that the GFS supplies 20-25 houses in the village. Every week, one guy from each house in the village will take turn to go to the hill and 'clean' the pipe.

Encik. Hashim showed the Black pipe. There is one external link of the pipe. Every week, they will open the external link of the pipe along it to flow, all the sediment will flow outside the external link of the pipe.THIS IS WHAT WE SO CALLED CLEANING.At the end, there would have no sediment left inside the pipe. Of cause, they will open each of the external link of the pipe from the hill until the last station for one hour. The cleaning time is usually in the morning, from 10am to 11am.
Within this 1 hour, the pressure of the water inside the pipe will decrease. It will have no water supply to the village temporarily. During that time, villager will use the water from the storage tank.

In addition, Encik Hashim also told us that at the side of the small road, there is a draining water come from the GFS. It is the excessive water flow out from the GFS (as in thr picture A - below). Just beside the drain, there is a paddy field. They will use the draining water to supply the paddy field. In order to control each of the flow of the water into that particular paddy field, there is a block which will be controlled by the villagers to determine which station of the paddy field need to be filled with water.

Overview of the water supply to the paddy field.

For example, if they closed the block, the water will be blocked to flow down(above picture). Water will be accumulated just before the block (Below - B). Once the water is full, there is another pipe which connect between the drain and paddy field ( Below - C). The pipe will direct the water to flow into the paddy field. ( Below - D)

A. Drain, B. Block, C- Pipe from Drain, D - Pipe to Paddy field.

As for another type of pipe- Black pipe with 2 white line (below), it is used to supply the water in the artificial pond. It is built by the villager because they are hardly to get the sea food due to the geographical area(near the mountain and hill). The artificial pond feeds the freshwater fish (not sea water) that are caught in the waterfall (of the GFS). All the villager can come and catch the fish in the pond anytime as it is belonged to all of the villagers.

Before going back to DHO, Encik Hashim went and plugged lots of rambutan to us. Then, that was the end of the BAKAS trip for the morning section.

Wednesday, July 14, 2010

DAY 9 - 14/7/2010 - CDC (Part 1)

Mr. Jamil, Penolong Pegawai Kesihatan Persekitaran, gave us the replacement talk on today. We just discussed about the overview of CDC,E-notis and outbreak investigation of food poisoning.

Mission: to prevent the communicable disease from occuring.

Objective of CDC:
1. Reduce disease incidence and mortality from infectious diseases that it does not become a threat topublic health.
2. Promoting a healthy lifestyle, appropriate preventive measures, detection and immediate treatment, ongoing monitoringand appropriate rehabilitation services.

3. Encourage public participation while the cooperation of various agencies / sectors to create communityhealthy and caring.

Enforcement of the Acts: -
1. Prevention and Control Act of Infectious Diseases 1988
2. Destruction of Disease-Bearing Insects Act 1975 (Amendment 2000)

The jobs covered by CDC:
1. Record for disease surveillance
2. collect and analyse the data.
3.investigate and detect the cause of the disease or contact person
4. planning for disease control.
5. take the speciment from suspected sample.
6. prepare the report or written
7. receive the order from higher authority ( State Health Officer)
Commonest Communicable Disease:
a. Foodborne and waterborne diseases: AGE, cholera, leptospirosis
b. Vector borne diseases:denggi fever, malaria, chikungunya
c. Preventable communicable diseases by vaccination: typhoid, polio, tetanus
d. Dry Cough: Tuberculosis, Leprosy
e. Sexual Transmitted Diseases: syphilis, gonnorrhea
g. Zoonotic Disease: plaque
h: world wide disease
i: New Diseases: H1N1, SARS

Disease Control: Kawalan Wabak (FWBD)
1. Formation of Bilik Gerakan
2. Formatin of Investigation Team
3. Team of Disease control and Sanitation
4. Health Education Team


Section 10. Requirement to notify infectious disease.

(1) Every adult occupant of any house in which any infectious disease appears, and every personin charge of, or in the company of, and every person not being a medical practitioner attendingon, any person suffering from or who has died of an infectious disease shall, upon becomingaware of the existence of such disease, with the least practicable delay notify the officer in chargeof the nearest district health office or government health facility or police station or notify thenearest village head of the existence of such disease.

(2) Every medical practitioner who treats or becomes aware of the existence of any infectiousdisease in any premises shall, with the least practicable delay, give notice of the existence of theinfectious disease to the nearest Medical Officer of Health in the form prescribed by regulationsmade under this Act.

(3) The person in charge of any boarding-house shall, with the least practicable delay, notify theofficer in charge of the nearest district health office or government health facility or police station ifhe knows or has reason to believe that any person in the boarding-house is suffering from or hasdied of an infectious disease.

(4) Any police officer or village head receiving notification under this section shall, with the leastpracticable delay, notify the officer in charge of the nearest district health office or governmenthealth facility.

(5) Any person who contravenes this section commits an offence.

(6) When any person is charged under this section, he shall be presumed to have known of theexistence of the infectious disease or to have had reason to believe that an infectious diseaseexisted, unless he shows to the satisfaction of the Court before which he is charged that he didnot know and could not with reasonable diligence have obtained knowledge of the infectiousdisease or that he did not have reason to believe that an infectious disease existed.

Notification of Diseases by telephone and followed by Notification of disease in the written form:
1. Dengue Fever or DHF2. Yellow Fever
3. Diphtheria
4. Ebola
5. Food Poisoning
6. Cholera
7. Plaque
8. Poliomyelitis
* for Chikungunya, notification is same as Dengue Fever

Notification of Diseases in written form within 1 week of duration after diagnosis:
1. Whooping cough
2. Measles
3. Chanchroid
4.Dysenteries (all form)
5. Gonoccocal infection (all form)
6. Leprosy
8. hand, FOot & Mouth Disease.
9. Relapsing Fever
10. syphilis (all forms)
11. Tetanus (all forms)
12.Typhoid & paratyphoid fevers
13.typhus & other ricketsioses
14. Tuberculosis
15. Ciral encephalitis
16. Viral Hepatitis
17. Any other life threantening microbial infection
18. HIV (all forms)

(Example of the graph)- number of cases cannot be published as it is P&C)
Green line shows the median. If the number of cases exceed more the red line ( 75percentile), something is going wrong right there. ExampleL week 15, 33, 42.. Action should be taken to investigate the cause.

General Definition: sudden onset of vomiting, diarrhea and other symptoms that are caused by food or drink.

Outbreak Definition: 2 or more cases which poses similiar symptoms after eating the same food or different type of food in a same food premise/ place.

Organization Cart:

Step of Investigation in Outbreak of Food Poisoning:

1. Confirm the cases: by disease notification according to district E-notis.

2. Form a team of outbreak investigation.

3. obtain the sample from the suspected spot: usually, there is nothing could be found because the food premise owner would have clean the spot before health officer team reach.

4. Implementing the steps of disease control and prevention
5. collect all the information related to the outbreak. Health officer will ask all the patients what they had eaten, type of food, duration. At the same time, another control sample with similar constant varible (2 - 5 times of the affected patients in the outbreak).E.g Outbreak of food poisoning in the school. 25 students are affected. 50-100 control sample from health students are selected.

6. Develop the hypothesis

7. Plan and investigated the epidemiological data: Odd ratio, attributary risk

8. analyze the data

9. Inteprete the data and make the conclusion

10. Make the record.
• Ordinary – FWBD/KRM/BG/001 Pind 2008
• Complex - FWBD/KRM/BG/001 Pind 2008 & Scientific Write up

Question to be asked during outbreak of Food Poisoning.

From the above statement, attributable risk is much more higher.

Odd ratio shows Nasi Goreng is the most probably food that cause food poisoing.

According to Mr. Jamil, Nasi Goreng and Ayam Goreng are the 2 commonest food that cause food poisoning not only in the Sik, but whole Malaysia. The affected place are usually school canteen and hostel.

Lastly, Mr. Jamil show us the E-notis. Due to private and confidential, the content is not allowed to post in here. Here is the link to E-notis: . For the user account of PPKP of CDC, SIK, only information of patients from SIK is available; similarly, user account of State Health Officer will be able to access patients information from that particular state only. Once log in E-Notis, number of cases of that week and number of cases in the year will be appeared.

Data of that particular patient such as IC number, address, date of admission, hospital name.... will be key in in the E-notis.It serves as a two-way communication tool, i.e. data flow from peripheral to center as well as from center to peripheral..If the case appears come from other district, for example, a patient from Kubang Pasu come to Hospital in Sungai Petani. Penolong Pegawai Kesihatan Persekitaran will key in the data and transfer the case to the E-notis of Kubang Pasu, not Kuala Muda. The information will be available to Kubang Pasu DHO and appropriate actions will be carried out. Conversely, if a disease is diagnosed at a DHO, the data entry is to be done by the DHO and available to the state as well as central level. However, this is rare because only confirmed cases will be entered into the system and confirmation normally done by laboratories in larger centers.

By using E-notis, number of cases per year (or any duration) could be sorted out in a table.The officers in charge are expected to keep themselves updated daily by logging in everyday. E-notis enables real time information sharing and make the notification process faster and easier. It is a very useful programme to evaluate the Communicable disease in the district

Day 9 -- 14/7/2010 - Part 2: Food Quality Control

Mr. Dzullkifri, PPKP supposed to come and give us a talk on Food Quality Control,but he was busy with the food premise operation, at the end, Mr. Asri, another PPKP of Unit KKM came to replace him.

The objective of KKM is to make sure all the food that are supplied to the community are safe, including those food are imported and exported, teach and encourage the commity to buy the safety and nutritonal food.
Specific objectives are:
1. Make sure all the food that sold to the public followed the standardized protocol, free of food contamination, contain labelling and advertising correct information of the food (do not confuse the public of that food).
2. Make sure food that is prepared, stored, sold and managed in a proper and clean condition.
3. Make sure the consumer understands the explanation on health education on food quality control.
4. Make sure all the food that are prepared always free of contamination and put into practise on the way to preserve the food.
Activities & Resposibilities :
1.Inspection of food premises
2.Closing food premises below standard
3.Food Sampling ( Physical, Chemical, Microbiology )
4.Confiscation Operation, especially in response to ‘food alert’ eg. Confiscation of all products containing Melamine.
5.Disposal of food substances that do not fulfill Food Act 1983 and Food Regulation 1985
6.Mineral Water Licensing
7.Bottled Drinking Water Licensing
8.Issue Health Certificate for export products
9.Investigation of Food poisoning
10.Investigation of spoilt/ contaminated / expired food complaints
11.Give the admission letter for Anti-typhoid Vaccination for all food handlers ( RM 20 , immunity for 3 years , done every Thursday )
12.Monitor food quality and hygiene in public occasions / gathering
13.Preparation of monthly and annual reports
14.Investigation and prosecution
15. Enact the Food Act 1983 and Food Regulation 1985
16. Health Education to the food premise owner

The Food Safety & Quality Unit comes under the jurisdiction of the following laws:

Based on the targets set by the Kedah Health Department, the unit is required to monitor at least 1450 food premises and take 1300 food samples each year. The action plan includes:

•Decreasing the incidence of food poisoning in schools / institutions
•To ensure food handlers comply with the required food standard and safety.


Last week 7/7/2010 , KKM from various district, including the Sik unit KKM had the Food Premise Operation Spot Check that is held annually, this is Operation VII. According to Mr. Asri , it supposed to be Operation VIII, the reason is that previous District Health Officer cancelled the activity. The reason that KKM from other district come to have operation together is to make sure that the PPKP does their job, because they know all the food premise owner, it is very difficult to 'compound' them.
Basically, a merit system encompassing various criteria is used to assess the food safety and quality:
• KMM 3P1 ( Restaurants/Food outlets/Kitchen)
• KMM 3P2 ( Food Stalls / Canteen)
• KMM 3P3 ( Stationary hawkers )

HOWEVER, it is replaced by the new merit system which standardize the assessment of food saftet and quality. In short, the 3 forms stated above are combined into 1 paper.

PPKM-2/09 (please magnify to see the content)

Food premises that fail to meet the required standard will be issued a closing order, as stated in Section 11, Food Act 1983 and order to clean the food premise. Closing order will be issued if the total score is less than 70% for schools and less than 60% for all other eateries. Lampiran 1 form is issued to close the premise.
In the event of borderline scores, the premise will be issued with warning letter (Lampiran 2) to increase the hygiene level and subsequent inspection will be done to assess the improvements, failure of which will result in the closure of the premise.
In addition to that, Sealing / Freezing and Disposal of food substances will be done based on Standard Operating Proceduring.Within this 2 weeks, food premise owner should clean the premise and call for PPKP to re-open their shop.

Food Premise Inspection Protocols
The spot check team should consist of various members from various district. This will prevent bias in the decision making whether need to 'compound' the owner or not. Firstly, PK (Pegawai Kesihatan or Health Officer) will check the food premises registry. Vaccination for anti-typhoid will be taken into consideration. If the owner does not take the vaccine, they will be warned to do so. PPKP will classify premises according to Colour tag Lot system. PK will isolate the premise into the inspection plan.PPKP identify the premise to be inspected, he is the one who determine which premise to be inspected.
During the Food Premise Inspection, I followed Mr. Dzullkrifi, some cases he selected were 'old case', however, most of the premises he pass by, he will stop and spot check. PPKP will prepare the equipment ( based on check list ), he then enter the premise and introduce himself and show the prove he is health inspector, present official power card and explain the purpose they come. Collection of information will be done. PK will inspect the food premise. They will identify the faults and verify the complaints. Photographs of the unhygienic environment and other problems are taken. PPKP will fill in the form and judge whether to compound the owner.
If sampling is required:
1.If sample is taken, explain to the owner/representative about the sample taken for analysis.
2.Give a copy of the inspection report to the owner/representative.
3.If sample is taken, send the sample for analysis and get formal reply from the lab declaring the reception of the samples.
4.Photos taken are sent for developing.
5.Prepare official report including the analysis findings and photographs.
6.Submit report to PKP.
7.Submit report to the person who made the complaint ( If necessary ).
8.Submit report and ID to the Investigation officer ( UPPD ) if inspection is associated with investigation.
9.Record and store exhibit in safe place.
10.Enter the report into the file ( open new file if the premise is new and register the premise into the premise registry)
11.Colour tagging for the file.
12.Written record
According to the target set by State Health Office, for example, the target is benzoic acid. PPKP will do his homework to find out what are the food contain benzoic acid. - eg. chilli sauce.
PPKP will enter the shop and introduce himself and show the prove he is health inspector, present official power card and explain the purpose they come. He will choose the food needed to be sampled (that contain benzoic acid). Then, he will make the payment for the thing he buy and get a receipt (penjual) or surat akuan sampling ( pengilang/pengimport). Sampling conduted based on Food Rules and Regulation 1985. Sample is sealed and labelled. 3 similar samples offered to the owner and make him choose 1 for him to keep. He will release sample collection notice as per section6(1) food act 1985.Other 2 samples are taken back to the office. Record sample details in the record book and prepare analysis request form. He will send 1 sample and along with this form (Borang A) to a lab(look for physical and chemical investigations) authorized by the officer in charge or through registered AR post and get a conformation letter from the lab once they have received the sample. He will select the content to be tested. For example, chilli sauce, he will choose to test concentration of benzoic acid.If the result is positive showing food does not fulfilled the requirement, result will be sent within 9days. Otherwise, Lab will send the result within 90 days. The 3rd sample is kept locked in a cabinet.
As for microbiological investigation, procedure almost the same, except Place the sample in the fridge filled with ice or cold packs. Date, time and temperature are recorded.Prepare analysis request form and send sample to an authorized lab immediately.Get a conformation letter from the lab once they have received the sample. Record the date, time and temperature.Record and update written record.