Relationship DPT ImmunizationStatus with Diphtheria

Based on Geographic Information System in Padang

Masrizal 1, Febi Damisti Ramadhani1
1
Public Health, Andalas University, Padang, West Sumatra, 21528, Indonesia
1
AndalasUniversity, Padang, West Sumatra, 21528, Indonesia

*Corresponding Author: Masrizal, E-mail: masrizal_khaidir@yahoo.com, Phone: +62-

8126733228, Fax: +62-8126733228

Background : This study aims to look at the effect of covariates variables (education,
knowledge, and attitude of the mother as well as density of occupancy bedrooms) to DPT
immunization status with diphtheria in children aged <15 years in the city of Padang based
Geografic Information System

Method: A case control study was conducted to the population of all mother of children
aged <15 years in the city of Padang on the existing districts of diphtheria cases which is a
probable case and a confirmed case. The total sample of 102 people, were taken by simple
random sampling, matching with gender, and region of residence closest to the sample cases.
Data was collected with interviews using questionnaires. Data were analyzed using
univariate, bivariate, multivariate and spatial.

Result: Bivariate analysis showed that the DPT immunization status, maternal education and
density of occupancy bedrooms related to diphtheria (p = 0.041; OR = 2.42) (p = 0.025; OR
= 0.333), and (p = 0, 0163; OR = 3.2). While the knowledge and attitude of the mother was
not related to diphtheria (p = 0.694) and (p =0.126). Final multivariate modeling indicates
that maternal education, maternal attitude, and density of occupancy bedrooms is
confounding the DPT immunization status with diphtheria.

Conclusion: Maternal education, maternal attitudes and density of occupancy bedrooms, has
an influence on the relationship status DPT immunization to diphtheria. Thus, it is expected
to the Local Public Health Center to improved of health promotion of immunization DPT
and information of the diphtheria, especially in the Kuranji East Padang and North Padang
subdistrict.

Acknowledgement: Thanks to Departement of Health Padang City.

Keywords : Diphtheria, DPT Immunization Status, GIS,

Background

Indonesia is a developing country that has a complex health problem that has
a mortality and morbidity are relatively high especially in communicable disease
problems. Communicable diseases are caused by microorganisms or toxinnya
transmitted by the reservoir to susceptible humans. One of communicable disease
that can lead to death is diphtheria.[1, 2]
Diphtheria is a communicable disease that is rarely happen. The disease is
caused by the Corynebacterium diphtheria (toxin-mediated desease) characterized by
the formation of membranes in the nasopharynx (called pseudomembrane) as well as
the toxin can spread into the bloodstream. If the toxin has spread into the
bloodstream so the toxin can damage the heart muscle (myocarditis), nerves
(neuritis), thrombocytopenia and proteinuria. Diphtheria is a communicable disease
that can be fatal if not treated or quickly given medication. The most severe
consequence is distruct or heart failure until sudden death.[1, 3]
Based Organitation World Health Organization (WHO) diphtheria in the
world has increased every year from 2012 to 2014. The number of cases of
diphtheria in the world in 2012 as many as 4490 cases and 2013 as many as 4680
cases. A large increase occurred in 2014 as many as 7321 cases. There are many
countries in the world that is still endemic diphtheria. The country is a parts of Asia,
Africa, and South America. India is a country that has the highest number of cases of
diphtheria in the past three years among countries around the world.[4]
Based on WHO among several countries of Asosiation Of South East Asian
Nation (ASEAN) from 1999 to 2014, Indonesia occupied the highest position of the
number of cases of diphtheria each year compared with the ASEAN countries.
Thailand, Laos, and Myanmar is the second highest number of diphtheria cases after
Indonesia each year. This means that Indonesia is a country vulnerable to contracting
diphtheria compared with the ASEAN countries.[4]
According to the Ministry of Health, in 2011 Indonesia recorded the number
of diphtheria cases as many as 806 cases and Case Fatality Rate (CFR) of 4.71%.
Increased in 2012 Indonesia has a number of diphtheria cases as many as 1192 cases
and CFR of 6.38%. In 2013 there were 778 cases and CFR 5,01% whereas in 2014
the incidence of diphtheria in Indonesia is as much as 396 cases and CFR of 4.04%.
Although in 2014 the number of cases of diphtheria declined, Indonesia remained the
highest order of occurrence of diphtheria among ASEAN countries.[5]
In Indonesia, the province has the highest number of cases of diphtheria were
East Java, West Kalimantan, and Banten. Among the provinces in Sumatra, West
Sumatra Province is the province with the highest number of cases of diphtheria. In
2012 there were two cases of diphtheria in Padang Pariaman district, in 2013 found
three cases of diphtheria. significantly increased in 2014 and 2015 jumped nine times
from the previous year as many as 9 and 85 cases of diphtheria and all of them are in
the city of Padang. Diphtheria is a communicable disease that is very dangerous. If
there is one case of diphtheria in the region will be said that the region is exposed to
Outbreak.[6-8]
Risk factors of communicable disease can be evaluated from an
epidemiological triad, which is agent, host,and environmental factors. Diphtheria is
caused by Corynebacterium diphtheria agent, host factors that immunization status,
nutritional status, as well as environmental factors namely the physical environment
of the house, neighborhood density, humidity, air temperature, access to health care,
education, knowledge and attitudes of the mother. According to research in 2008
Basuki Kartono that the most dominant factor affecting the incidence of diphtheria is
immunization status. In 2012 the coverage status of DPT-HB 1 and DPT-HB3 in
Padang is very low 63% and 57.9%. In 2014 the immunization coverage of DPT-HB
1, DPT-HB-2 and DPT-HB-3 in Padang is respectively 56.9%, 59.4% and 61.1%.
Distribution coverage status DPT-HB 1, DPT-HB 2 and HB 3 DPT-lowest among
existing health centers in the Padang city in 2014 were in the working area of
Belimbing health centers respectively 28.45%, 40.5% and 42.0%.[8-10]
Geographic information system (GIS) is a system that can be used to describe
the magnitude of health problems and identify the specific determinants of health. By
mapping it will be able to see the distribution of the disease based on the region and
identify patterns of distribution of the disease so as a way to solving effectively and
efficiently the problem. Spatial analysis aims to look at the overlay diphtheria with a
population density each sub-district in 2014 and coverage DPT immunization status
in sub-district, the distribution of diphtheria based on risk factors, as well as knowing
the distribution pattern of diphtheria in Padang [11]
Methods

This study uses primary and secondary data. The study design of case control
study with matched gender-based geographic information system. The number of
samples in the study 102 people consisting of 51 cases and 51 controls. Analysis of
data using univariate, bivariate using Mc Nemar test, multivariate logistic regression,
and spatial analysis use distribution and overlay analysis. The data is processed by a
computer using software Epi Info 7 and Arc Gis 9.3.

Results
The frequency distribution of characteristics of children indicate that the child
is based on the sex, both men (54.90%) and women (45.10%) relatively same.
Children who have incomplete DPT immunization status more the case as many as
18 people (35.29%) than the control group of 8 people (15.69%). Children who do
not qualify more room occupancy density in the case group of 31 people (60.78%)
than in the control group as many as 20 people (39.22%).
The frequency distribution of characteristics of the mother show that mothers
with low educational less in the case group as many as 6 people (11.76%) than in the
control group of 16 people (31.37%). Mothers who have poor knowledge more in the
case group as many as 32 people (62.75%) than in the control group of 30 people
(58.82%). Mothers with more negative attitudes more in the case group as many as
19 people (37.25%) than in the control group as many as 12 people (23.53%).
The statistical test of the relationship of independent variables and the
covariates on the incidence of diphtheria shows that for DPT immunization status
variable obtained p-value = 0.041, meaning that there is a significant association
between DPT immunization status with the incidence of diphtheria. Mother
education variable obtained p-value = 0.025, meaning that there is a significant
association between maternal education with the incidence of diphtheria. Variable
maternal knowledge obtained p-value 0.694, meaning that there is no significant
relationship between mother's knowledge with the incidence of diphtheria. Maternal
attitude variable obtained p-value = 0.126, meaning that there is no significant
relationship between mother's attitude to the incidence of diphtheria. Room
occupancy density variable was obtained p-value = 0.016, meaning that there is a
significant relationship between room occupancy density with the incidence of
diphtheria.
 The final model of multivariate analysis showed that there is no interaction
variables against DPT immunization status with the incidence of diphtheria. The next
in the test confounding showed that all variables which is variable of final model are
confounder variables on the status of the DPT with the incidence of diphtheria,
which means that children who have the status of DPT incomplete in the same
condition is influenced by other variables (mother's attitude, density occupancy, and
the mother's education).
Figure 1 show that spasial analysis in overlay between two variables, the
incidence of diphtheria and population density all districts in the Padang city.
Distribution of cases of diphtheria are common in sub-districts with the highest
population density which is East Padang sub-district, North Padang Sub-district and
Nanggalo sub-district is more than 7309 persons / km2 with 19 cases.
Figure 1: Overlay Map of diphtheria and Population Density in Padang

An overlay or overlaying between two variables, cases of diphtheria and

coverage of DPT immunization status in sub-district in Padang. Distribution of cases
of diphtheria in the sub-district which has a low coverage of immunization status
more than in the district which has the status of DPT immunization coverage high-
districts.
 Figure 2: Map Overlay incidence of diphtheria with the DPT Immunization
Status in Padang

Figure 2 show that of Nearest Neighbor Analysis (NNA) which indicates that
the value of Z Score = -13.66, meaning that the distribution pattern of diphtheria
cases have a tendency grouped or clustered. Grouping of incident cases of diphtheria
in the Kuranji sub-district, and East Padang sub-district North Padang sub-district.
Table 4. Results of Analysis Nearest Neighbor Analysis Diphtheria Genesis
Significant Level Critical Value Nearest NeighborRatio
Pattern
(p-value) (Z-score) Z-Score P-Value
0.01 -2, 58 -13.66 <0.01
Clustered 0.05 -1.96
0.10 -1.65
Random - -
0.10 1.65
Dispeared 0.05 1.96
0.01 2.58

Discussion

Table 4 show that case control study research have downside which is in the
form of a validation bias where difficult for obtained the information from the field.
Theoretically many other factors related to the occurrence of diphtheria, because of
limitations of the researcher, this study only examined several variables, among other
DPT immunization status, knowledge, education, attitudes, and room occupancy
density
Based on the results of the univariate analysis explains that children with DPT
immunization status incomplete is more in children with diphtheria than in children
without diphtheria. This is consistent with previous research. DPT immunization
status incomplete is DPT immunization status less than 3 times the basic DPT
immunization. DPT immunization is a diphtheria pertussis tetanus immunization
made from antigens or inactivated bacteria so that stimulate the body's antibodies out
so resistant to the disease. It will stimulate the human immune system's memory can
be against an antigen that when it invade the body.[12-13]
Based on the characteristics of the mother, the child with diphtheria more have
mothers with high education of the poor education. This is not consistent with the
Feranita utama research that children with diphtheria that more had mothers with low
education levels than higher education. In addition, children with diphtheria more
had mothers with less knowledge than good knowledge. It is not consistent with Putri
MS research but, according to Basuki Kartono research that children with diphtheria
more had mothers with less knowledge. Same thing attitude of the mother variable,
that negative attitude found in children with diphtheria than children without
diphtheria it is supported by Lestari Kusuma Scorpia research about diphtheria the
incidence.[8, 10, 14-15]
DPT immunization status are major risk factors that lead to diphtheria which
had 2.42 times if it has a DPT immunization status is incomplete. This research is
supported by previous research. According to Basuki Kartono research that DPT
immunization status is the dominant risk factors that cause diphtheria with risk 46.6
times[10, 16]
The results in the analysis mulivariat see two things: the effects of interaction
and effects of confounding. Statistical test results showed that all the variables
included in the multivariate analysis was confounder, but there is no interaction
effect. This means that children who have incomplete immunization status in the
same conditions affected by maternal education, maternal attitudes and room
occupancy density to be exposed to diphtheria.
Children aged <15 years who have incomplete DPT immunization status will
be susceptible to diphtheria. In the same condition, it is influenced by maternal
education, maternal attitude and room occupancy density. High education will
influence how the mother's knowledge. Maternal knowledge will influence maternal
attitudes towards immunization and diphtheria. A positive attitude towards diphtheria
will encourage mothers to act away from the risk of diphtheria. Eligible room
occupancy density 4m2/ person. Knowledge influence how mother to actions and
attitude about the source of transmission of the disease so that it becomes another
factor supporting the child to be exposed to diphtheria besides the main factor DPT
immunization status.[17]
The results of spatial analysis NNA analysis showed that the distribution
pattern of diphtheria cases in Padang City is clustered in Kuranji sub-district, North
Padang sub-district, East Padang sub-district. Techniques overlay in spatial analysis
shows that there is a relationship diphtheria with immunization status and population
density every district. This caused that the more densely populated districts and more
cases of diphtheria. Similarly with DPT immunization status. The lower coverage the
DPT immunization status The higher frequencies of cases of diphtheria in the
region.[18]

Conclusions
Children with diphtheria have more mothers less knowledge than mothers
with good knowledge. Maternal education, maternal attitudes and room occupancy
density is confounder of the DPT immunization status with the incidence of
diphtheria. This mean that the DPT immunization status is incomplete in the same
state is influenced by confounder variables to be exposed to diphtheria. So that,
expected to primary health care to continue to provide proactive health promotion,
especially regarding immunization and diphtheria.

Acknowledgement
Thanks to Departement of Health Padang City.

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