In the Depth of Asmat Regency, a part of the Larger Province of Papua, Indonesia
Located on the southwestern coats of Papua, a regency which borders the Arafura sea, is the regency of Asmat—one of the nine major regency located on the Province of Papua. Asmat covered a total area of 29.000 square kilometers or as equal as 48 times the size of DKI Jakarta. This regency consists of many districts, including Agats and Sawaerma. Asmat is embraced with heavy rainfall, thus making the landscape of Asmat to be very unique—where most of the land is covered by hanging board streets due to the mushy ground (Fig 2). The geographic condition of Asmat, which is mostly predominated with muddy swamps and rivers, is assumedly one of the triggers of the malnutrition outbreak, where some of the children in Asmat drink the water from the river for daily consumption.
Malnutrition and Measles Outbreak in Asmat
Outbreak of measles and malnutrition has occurred in Asmat, causing the death of 72 children—66 died due to measles and 6 died due to malnutrition. Until now, there have been six similar outbreaks that have occurred in Asmat, and the recent one is apparently the worst. This outbreak is presumably occurred due to the un-complete vaccination and the geographical condition of Asmat—making health approach to be rather difficult. Patients’ limited understanding towards the schedule of vaccination and the difficulty of educating parents are some of the reasons why children didn’t undergo complete vaccination.
The Government of Asmat and their team had expanded their reach from the original plan of 7 districts, into 23 districts. The area of work is challenging due to the strenuous geographic field and the lack of medical personnel. Pulau Tiga district, the first place where death due to measles and malnutrition was reported, for example—where most of the victims died before they could reach the hospital due to the great distance between the village and the Public Hospital (RSUD) of Agats, the capital of Asmat, which can only be reached by using boat. The distance can be reached in 3 hours by using speedboat, but may took a whole night using traditional boats which villagers normally use.
Seeing the aspect of the disease itself, measles is a very contagious infectious disease which is caused by the Morbilli virus, characterized by fever, flu-like syndrome, watery eyes, the appearance of small red spots on the buccal side of the mouth, and rash that occurs from the head, to the body and limbs, accordingly. This disease is mostly contagious few days before and after the development of rash—thus, preventing transmission can be quite challenging due to the unspecific symptoms. Complications, which are the leading cause of death in patients with measles, include diarrhea, pneumonia and encephalitis (the inflammation of the brain). Children with malnutrition usually shows the symptoms of being anorexic with visible rib lines and baggy-like wrinkled skin.
Help is Here—Indonesian Ministry of Health’s Response
On the January 16th 2018, the Indonesian Ministry of Health has sent the first Flying Health Care (FHC) team which consists of 39 health personnel (11 medical specialists, 4 general practitioners, 3 nurses, 2 anaesthesiologists, and other 19 health personnel including nutritionists, environmental health experts and surveillance). As much as 2.1 tons of medicines (weight excluding food supplies) have been distributed to the regency of Asmat, which include antibiotics such as amoxicillin, anti-bacterial ointment, paracetamol, infusion, vitamins, and other drugs.
On the 25th of January 2018, the Minister of Health, Prof. Dr. dr. Nila Farid Moeloek, has arrived in Asmat—where she directly visited and monitored patients in the public hospital of Agats. On the same day, she held a meeting between the heads of the districts’ health office in Papua.
On the 26th January 2018, the second batch has departed with 36 health personnel which include 11 medical specialists, 4 general practitioners and 21 other health experts. Together, with the help of the local health officers, TNI, polices and the Ministry of Social Affairs, they have been providing health care assistance to the people of Asmat. Since September 2017 until January 28th of 2018, the health care team has examined 12.841 children in 23 districts in Asmat Regency. The result shows that 646 children had measles, 218 were malnourished and 11 had both measles and are malnourished. These patients were then evacuated to the public hospital of Agats to receive intensive care and treatment.
On the February 5th, the outbreak status was removed, but the Government will remain continuing their work to secure the post-recovery state. Remaining patients that were currently undergoing treatment in Asgat Public Hospital were as many as 12 children—nine were still malnourished and the rest were due to measles.
Through the work of the Ministry of Health and all the team who participated, by the 5th of February, there were 17.337 children (0-15 years old) who got vaccinated, 121 were hospitalized in the Public Hospital of Asgat and 57 were cared for at the Aula GPI (due to the limited space of the hospital); with the total of patients with measles were as many as 651 and patients with malnutrition were as many as 223 children. Complications of both measles and malnutrition occurred to 11 children, while 25 more were suspected with measles. Until the outbreak status was removed, there are a total of 72 deaths—66 were due to measles and 6 were due to malnutrition.
On the 11th February, it has been reported that there were 12 children with malnutrition, 3 children exposed to measles and 2 children with measles and malnutrition complications remains. They were all hospitalized in the public hospital of Agats.
By February 15th, the forth FHC team have arrived in Asmat—where they will continue to assist in strengthening health care and managing assistance in the public hospital of Agats through this recovery state. The Government will continue sending FHC teams months from now. Moreover, the Government will send as many as 120 personnel of Nusantara Sehat (NS) to 16 Puskesmas for placement for 2 years to help with the initial recovery period and stabilization.
Knowing What They Did: Health Personnel Approach to Patients
A pediatrician, who was part of the FHC team, shared his experience in managing patients is Asmat. Patients who were diagnosed with measles requires antibiotic treatment, optimal nutrition intake and vitamin A supplementation to speed recovery, reduce the severity and prevent against subsequent complications. Some patients had already developed complications such as diarrhea, pneumonia and dehydration due to minimal intake and loss of consciousness—hence were given special treatment. Malnourished patients, on the other hand, were given special-formulated milk packed with high calories made by the doctors themselves—this, is to boost children’s growth. The doctors also taught parents to make their own special-formulated milk.Patients with poor nutritional status were given adequate nutritional intake to boost their weight. “By giving patients the right amount of dietary intakes, they would most likely to experience weight gain as much as 5-10 gram per kg of the patients’ original body weight, each day. Thus, it usually takes 9 until 10 days to monitor patients’ weight gain progress.” as stated by a clinical nutritionist, which is a part of the team. She said that some of the malnourished patients were also infected by worms and thus were given rehydration, multivitamins and anthelmintic (to kill worms).
It is important to note that when children are infected with infectious diseases such as measles, they tend to have lack of appetite and inadequate dietary intakes—thus making them prone to poor nutritional status. Moreover, malnourished children are more vulnerable to experience infection. On the other hand, patients with measles are most likely to experience lower immune response towards other infection, hence are vulnerable to have secondary infection. Aside from malnutrition and measles, there were also cases of malaria, acute diarrhea, pneumonia and severe anemia.
Other than giving personal health care services, the team also help to provide counseling to the community. On the 20th of January, more than 200 breastfeeding mothers and pregnant women, whom some even came with their children, gathered in a sport hall in Agats, where they participate in the monthly health counseling. “The first thousand days of life” was the themed for that day. The team’s gynecologist and clinical nutritionist took their part to educate about the importance of giving distance towards births and fulfilling children’s right in having adequate nutrition intakes.
- Melihat anak-anak di Asmat yang dilanda wabah campak dan gizi buruk [Internet]. BBC Indonesia. 2018 [cited 9 February 2018]. Available from: http://www.bbc.com/indonesia/majalah-42893360
- Indonesian Ministry of Health’s Reports of Asmat. Kementerian Kesehatan Republik Indonesia [Internet]. Depkes.go.id. 2018 [cited 17 February 2018]. Available from: http://www.depkes.go.id/index.php?txtKeyword=asmat&act=search-action&pgnumber=0&charindex=&strucid=&fullcontent=&C-ALL=1&C1=1&C2=1&C3=1&C4=1&C5=1