Simvastatin Obat Kolesterol Tinggi

Indikasi dan Kontraindikasi

Simvastatin telah dikenal orang sebagai obat kolesterol tinggi (hiperkolesterol) atau gangguan lemak tubuh (dislipidemia). Obat ini dimasukan sebagai golongan obat statin atau disebut juga golongan obat HMG CoA reductase inhibitors atau obat penghambat konversi lemak tubuh. Selain simvastatin, terdapat beberapa obat statin lainnya, yakni atrovastatin, fluvastatin, lovastatin, pravastatin, dan rosuvastatin.

Tidak seperti golongan obat penurun lemak lainnya, manfaat utama statin ialah menurunkan LDL. LDL adalah lemak utama penyebab penyakit jantung dan stroke yang biasa dikenal orang sebagai kolesterol jahat. Dengan demikian simvastatin disebut “kardioprotektor”, yakni melindungi jantung dari penyakit dan serangan jantung.

Simvastatin juga dikenal memiliki efek pleiotrofik, yakni khasiat yang banyak selain untuk menurunkan lemak. Simvastatin terbukti dapat menurunkan angka kasus penyakit jantung koroner, memperbaiki kondisi gula darah, menurunkan angka kasus stroke, dan bahkan bisa menurunkan kematian.

Simvastatin tidak boleh diberikan pada pasien atau kondisi berikut:

1.     Alergi (hipersensitif) terhadap simvastatin;

2.     Penyakit hati akut;

3.     Kehamilan;

4.     Wanita yang sedang menyusui;

5.  Tidak boleh diberikan bersamaan dengan obat-obat berikut: ketokonazol, eritromisin, klaritromisin, obat HIV inhibitor protease, siklosporin, gemfibrozil, dan danazol.

Efek samping 

Karena khasiatnya yang baik bagi jantung, simvastatin sudah seperti “obat umum” yang aman dikonsumsi setiap hari. Efek samping jarang muncul, dan efek samping muncul biasanya akibat pemberian dosis yang terlalu besar. Beberapa efek samping yang pernah dilaporkan beserta persentase angka kejadiannya:

1.     Sulit buang air besar (konstipasi) (2%);

2.     Infeksi saluran napas atas (2%);

3.     Banyak buang gas (1-2%);

4.     Peningkatan enzim hati (1%).

Dosis

Simvastatin tersedia dalam bentuk tablet dengan ukuran dosis 5 mg, 10 mg, 20 mg, 40 mg, dan 80 mg. Simvastatin tersedia luas dalam bentuk obat generik maupun paten. Simvastatin cukup diminum satu kali sehari dan paling bagus bila dikonsumsi pada malam hari.

Untuk menurunkan lemak, dosis simvastatin yang diberikan ialah 5-40 mg satu kali per hari. Pertama-tama pasien diberikan dosis 10-20 mg dan dilihat responnya. Pada pasien dengan risiko tinggi penyakit jantung, simvastatin dapat diberikan dalam dosis lebih tinggi, misal 40 mg. Hal ini karena target lemak pada pasien tersebut lebih rendah dari pada orang normal.

Sumber :

http://www.kerjanya.net/faq/4842-simvastatin.html

Transmissible Gastro Enteritis, TGE

TGE is a very important and highly infectious disease caused by a coronavirus.

Coronaviruses take their name from the halo-like array of envelope proteins that surround the capsid; they're visible in a TEM negative stain as spiky processes forming a "crown" around the RNA core.

The virus is killed by sunlight within a few hours but will survive for long periods outside the pig in cold conditions. It is very susceptible to disinfectants particularly iodine based ones, quaternary ammonia and peroxygen compounds. 

Disease will persist in the farrowing houses over a period of 3 to 4 weeks until sows have developed sufficient immunity to protect the piglets. 

In herds of less than 300 sows the virus is usually self eliminating provided there are good all-in, all-out procedures in farrowing houses and grower accommodation. In larger herds however the virus will persist in the growing herd because piglets at weaning, still under the influence of the maternal antibody, move into houses where the virus still persists. Once the lactogenic immunity in the sow's milk is no longer being taken in the pigs become infected allowing the virus to multiply. The pigs then shed the virus, contaminating the weaner rooms and infecting pigs being weaned after them. TGE can become endemic in herds in a mild form with high morbidity but low mortality. 

This disease in the weaning and the growing pig is clinically indistinguishable from porcine epidemic diarrhoea. In small grower-finisher units the virus is likely to disappear from the population. In large finishing units in which susceptible pigs are being brought in frequently, the virus is maintained indefinitely in the population by repeated infection of the newcomers.

Symptoms

Weaners & Growers

• When the virus is introduced into a finishing herd for the first time there is rapidly spreading, vomiting and a watery diarrhoea, eventually affecting almost all the animals.
• Disease disappears spontaneously over a 3 to 5 week period.
• Mortality is usually low.
• The main effect on the individual growing pig is dehydration which is resolved in about a week.
• Nevertheless the disease may increase the slaughter age by 5-10 days.

Piglets

• In the sucking piglet the disease is very severe.
• Acute watery diarrhoea.
• Almost 100% mortality within 2 to 3 days in piglets under 7 days of age due to severe dehydration and electrolyte imbalance.
• There is no response to antibiotic therapy.
• The most striking feature is the wet and dirty hairy appearance of all the litter due to the profuse diarrhoea.

Sows

• In acute outbreaks the most striking feature is the rapidity of spread.
• Vomiting.
• Diarrhoea.
• Adult animals show varying degrees of inappetence and usually recover over a 5 to 7 day period.

Causes / Contributing factors

• The virus is shed in large numbers in the faeces.
• Pig faeces therefore are the major source of transmission either directly through the purchased carrier pig or indirectly through mechanical transmission.
• Poor pen floors.
• Poor pen hygiene associated with bad drainage
• Poor hygiene procedures, between pens
• Environmental contamination from one pen to another i.e. boots, brushes, shovels clothing etc.
• Feeder pipes and feed bins. This is a high risk source for the spread of enteric diseases.
• Dogs may shed the virus in their faeces for 2 to 3 weeks.
• Birds and in particular starlings may transmit the disease.
• Contaminated feed.
• Continual use of buildings without all-in, all-out may perpetuate disease.
• Continual purchase of naive weaners.

Diagnosis

The clinical picture in acute disease is almost diagnostic. There are no other enteric diseases that spread so rapidly across all pigs. The ultimate diagnosis of TGE must be made in the laboratory from the intestine of a fresh dead pig using fluorescent antibody tests (FAT's). Isolation of the virus is also carried out. 

The best test, which will give an answer in a matter of hours, is to freeze the ileum (last part of the small intestine), section it for histology and carry out fluorescent antibody tests (FATs) on the sections. ELISAs may also be available in some more sophisticated laboratories. Polymerase chain reaction (PCR) tests would be possible but are probably not available. The blood samples can be subjected to serum neutralisation tests to detect rising antibody titres. Unfortunately these results take at least 2 weeks.

Similar diseases

Porcine epidemic diarrhoea (PED) could give a similar picture but it would be less acute and with less mortality in sucking pigs. 

In the acute form epidemic diarrhoea could give a similar picture but it would be less acute and with less mortality in sucking pigs. Where TGE has become chronic then differentiation from the other causes of diarrhoea must be carried out in a laboratory. If the herd has been infected previously with TGE and there are scour problems persisting it is necessary to determine whether the virus is still present or not. 

Treatment

• There is no specific treatment for TGE.
• Antibiotic treatment by mouth in individual piglets may reduce secondary infections.
• Provide easy access to water containing electrolyte and an antibiotic such as neomycin. Make this available to the litters twice daily.
• Improve the nursing and environment of the litter by providing extra heat and deep bedding to reduce the weights of infection from the diarrhoea.

Management control and prevention

• As soon as disease is suspected isolate those farrowing houses not infected, by using separate personnel boots and coveralls. This is particularly important in piglets under 14 days of age. The longer the disease can be kept away the more pigs will be reared and mortality reduced.
• If it is possible move sows that are within 3 weeks of farrowing from the farm before they become infected so that they could farrow down in an isolated building or outside in arks and escape disease.
• It is essential to develop immunity in the dry sows as soon as possible.
• There are two methods, either squeeze the piglets abdomen and collect the diarrhoea into a bowl or use sawdust or shavings in the areas where the piglets are scouring. Paper towels can also be used to soak up piglet faeces. This material is then mixed with a bucket of water and fed to the pregnant sows, (feed back).
• A further method is to collect the small intestines from a number of pigs that have died and macerate them in a food blending machine. The liquid provides a rich source of virus and this can if required be preserved by deep freezing.
• The disease should be spread as soon as possible across the whole farm. The object is to get a good immunity developed in the shortest possible period of time. It will take approximately 3 to 4 weeks to achieve this.
• Once the infected period is over ensure an all-in and all-out management system of the farrowing houses, weaner and finisher accommodation.
• Disinfection of pens between batches should be carried out using an iodine based disinfectant or one highly active against viruses
• This cleaning process is an important one to ensure the virus does not linger on the farm and become endemic.
• If your herd as become infected with TGE ask the question why and how? Look at all your prevention procedures and biosecurity as discussed in chapter 2. (Do this before you get TGE).
• Always provide boots and protective clothing for any one entering your farm.
• Provide disinfectant foot dips at all entrances.
• Keep starlings and migrating birds away from the farm by not exposing them to feed.
• Do not borrow equipment from another pig farm.
• Site all bins to the exterior of the unit and always have your own feeder pipes to your own feed bins. This is a high risk source for the spread of enteric diseases.
• Vaccination - live modified and killed vaccines are available in some countries. The results in the field are very variable. The objective is to maintain immunity in the colostrum. This can only be carried out by stimulating the gut of the sow to produce antibodies in the milk. Intra-muscular vaccines give a very poor response.

Source:

http://www.thepigsite.com/pighealth/article/301/transmissible-gastroenteritis-tge/

http://www.doctorc.net/HISTO%20CASEBOOK/TGE%20IN%20SWINE/TGEDISCUSS.htm

Advancing the key elements for One Health approach in Member Countries and Partner Organisations.

There are the identified actions for the eleven key supporting elements in order to foster a functional multi-sectoral collaboration.

1. Political will and high-level commitment

Country representatives recommended formation of national multi-sectoral committee and creation of National Strategic Plans supported by legislation or regulation while partners suggested the establishment of regional support units and creation of regional framework for epidemiology that can serve as basis for the countries to follow. Other suggestions from country representatives included the need to demonstrate the economic impact of zoonoses and to seek support and intervention from international organisations.

2. Trust

Country representatives recommended establishing a multi-sector steering committee that meet regularly involving concerned fields like agriculture, human health, fisheries, forestry, environment and the military. It was suggested to foster transparency between sectors and establish clear Terms of Reference (TOR). Creation of an integrated zoonosis as well as risk communication program on disease control was also suggested taking into account both the animal component and the human health component. Further, mechanism for cross-sector must be enhanced especially in terms of sharing of information, surveillance and response, and laboratory and risk communication. Partners, on the other hand, suggested strengthening networks through the SEAOHUN as well as the epidemiological and laboratory networks and conduct several joint trainings to build trust.

3. Common objectives and priorities

Under this element, it was suggested to form a functional multi-sectoral One Health committee and develop an integrated strategic plan and strengthen surveillance data sharing. For partners, it was recommended to identify priority diseases, both at the regional and country levels. It was also suggested to build a common objective and consider the focused areas under APSED and employ a participatory approach in planning and decision-making for a common objective.

4. Recognition of shared benefits

Development of a monitoring mechanism and sharing of success stories were identified as key actions under this element. There should also be co-ownership in prevention and control of diseases. Partners suggested having donor coordination to maximise result and outcomes and minimise cost of the activities. They likewise recommended applying the APSED approach for sharing in risk management.

5. Strong governance structures, aligned legal frameworks and recognition of existing international standards

Country representatives suggested increasing advocacy of One Health to leaders at the central, regional, and township and formation of national One Health committee with shared vision and mission and a clear term of reference with identified secretariat from each sector. They also suggested reviewing the list of existing legislation including the list of notifiable diseases and involve the three sectors of animal health, public health, and environmental health in the review process. Meanwhile, partners suggested adoption of OIE standards and management of human resources and application of APSED approach.

6. Adequate and equitably distributed resources

Under this element, country representatives recommended harmonising zoonoses priority and conduct advocacy especially to decision makers. They also suggested enhancing human resources and strengthening of institutional mechanisms and employ budgeting for integrated planning. Partners on the other hand suggested coordination among donors such as USAID and AusAID to determine how to distribute resources.

7. Identification and involvement of all relevant partners

Country representatives recommended the development of database of relevant partners through the appropriate authorities for 35 |The 3rd Regional Workshop on Multi-Sectoral Collaboration on Zoonoses Prevention and Control information sharing and establishment of animal vaccine bank. They also suggested online information sharing and consultative collaboration between relevant partners. Partners suggested the conduct of partner forum and consortium meetings. Each partner should implement its core business and respect others parners’ core business.

8. Coordinated planning of activities

Key actions identified under this element included identification of priority diseases relevant to partners and stakeholders and development of a plan of action; constitution of core committee for coordinated implementation of various activities, timelines, individual responsibilities including resources and monitoring; and conduct of regular multi-sector meetings. Partners recognised the need for regional support units and to have an effective common strategic framework and integrated plan to improve coordinated planning including surveillance among sectors and for selected diseases such as rabies and zoonotic EID.

9. Guidance on implementation of cross-sectoral collaborations

Several key actions were identified under this element by country representatives. These included suggestions to arrange orientation meetings for parliament members and policy makers to increase awareness and convince them of the importance and economic significance of a One Health approach; introduction of the One Health concept at the undergraduate level for all students of animal health, human health, and environmental sciences by inclusion of one- to two-hour credit course on One Health; development of standard operating procedures (SOPs) for outbreaks handling, data sharing, and response mechanisms; conduct of workshops for field veterinarians and human health professionals on joint epidemiological investigations and control strategies for zoonotic diseases; conduct of advocacy campaign; and involvement of the communities and private sectors. Partners meanwhile suggested developing One Health core competencies for each profession to be guided by SEAOHUN and to develop country strategic framework including guidelines for value chain analysis and implementing guidelines.

10. Capacity development

Conduct of needs assessment was suggested by country representatives including involvement of stakeholders in the development of curriculum. They recognised the need for a detailed plan and timeline as well the certification of laboratories. Partners suggested the use of PVS as guideline and development of training materials to focus on specific diseases and specific purpose such as research, programming management, and implementation.

11. Strong and effective health systems within the individual sectors

Country representatives recognised the need to utilize APSED as a tool to strengthen health systems in individual sectors and have adequate resources, to develop the human resources in individual sectors. Partners recognised the need to strengthen coordination and develop other technical support systems like epidemiology and laboratory, and strengthen public private partnership.

Resource :

The Third Regional Workshop on Multi-Sectoral Collaboration on Zoonoses Prevention and Control: Leading the Way on One Health. 26-28 November 2012. The Patra Bali Resort, Bali, Indonesia.

Tiga Daerah Percontohan Bersiap untuk ‘One Health’

Sebagai bentuk komitmen untuk mendukung implementasi Program EPT2, Pemerintah Indonesia telah menunjuk Bengkalis (Provinsi Riau), Ketapang (Provinsi Kalimantan Barat) dan Boyolali (Provinsi Jawa Tengah) sebagai daerah percontohan untuk pencegahan dan pengendalian penyakit menular baru dan zoonosis  menggunakan pendekatan One Health.

Bengkalis, Ketapang dan Boyolali dipilih berdasarkan beberapa faktor, yaitu:

1.     Pemicu munculnya penyakit dan potensi spill-over penyakit dari hewan ke manusia;

2.     Potensi amplifikasi dan penyebaran penyakit;

3.     Dukungan dan antusiasme yang tinggi dari pemerintah daerah.

Pendekatan One Health mengedepankan keterlibatan para pemangku kepentingan di tingkat nasional dan daerah, di mana dukungan politik dan operasional dapat dicapai secara intensif dan berkelanjutan untuk mencegah dan menangani penyakit menular baru (emerging) dan yang muncul kembali (reemerging) secara terpadu.

Melalui pendekatan One Health yang menekankan pada interaksi manusia, hewan dan lingkungan, para pemangku kebijakan disinergikan untuk melakukan kolaborasi multi-sektoral. Dalam hal ini, investigasi wabah penyakit di lapangan dilakukan secara bersama-sama oleh Kementerian Pertanian, Kementerian Kesehatan dan Kementerian Kehutanan dan Lingkungan Hidup.

Penunjukan tiga daerah percontohan tersebut merupakan hasil dari lokakarya yang dilaksanakan pada bulan April 2016, yang mempertemukan para pemangku kebijakan dari berbagai unsur, antara lain Kementerian Koordinator Bidang Pembangunan Manusia dan Kebudayaan, Komisi Nasional Zoonosis, Kementerian Pertanian, Kementerian Kesehatan, Kementerian Kehutanan dan Lingkungan Hidup, Kementerian Dalam Negeri, Badan Nasional Penanggulangan Bencana, Pemerintah Provinsi Riau, Provinsi Kalimantan Barat dan Provinsi Jawa Tengah, FAO, USAID, dan WHO.

Sumber :

FAO ECTAD Indonesia News Letter, Edisi 01, Aug – Nov 2016.

Zoonotic Diseases Action Package

I. How do Action Package leading countries engage other participating countries? 

1.     To explore the participation of other countries and organizations in ZDAP and possible solicitation to join and / or play a ZDAP leadership role

2.     All GHSA participating countries must strengthen their use of PVS in harmony with IHR 2005 within JEE and other tools in line with the targets stated in their ZDAP Road Map taking into account lessons learnt and best practices adopted in other countries

 

II. What are the challenges and opportunities in implementing the GHSA Action Packages roadmap?

•      Challenges and opportunities identified in the use of PVS and IHR 2005 within JEE tools, particularly in the areas of coordination, Collaboration and an appropriate balance in sector representation shall be rectified.

III. Current Activities (2014 - 2016)

1.     Building Global Commitment to Multi sector Approach to Manage Emerging Zoonotic Diseases in Support of the GSHA within the framework of Public Health.

2.     ASEAN Strategy on Rabies Elimination and the Action Plan.

3.     Update activities with GHSA steering group.

4.     OIE conference in Paris in June 2015.

5.     International Conference on ZDAP in Viet Nam àZDAP Action Plan.

6.     The Asia – Pacific Workshop on Multisectoral Collaboration for Prevention and Control of Zoonoses in Saporo Jepang in 2015.

7.     Global elimination of dog-mediated human rabies – The Time is Now, and the technical pre-meeting with the WHO Collaborating Centers in Geneva in 2015.

8.     Send assessors to JEE.

9.     2^nd ZDAP meeting at Ritz Carlton Mega Kuningan Jakarta 22 August 2016.

IV. What are the coordination mechanism and efforts to be taken to strengthen the Action Packages?

1.     Effort will be made to improve (non-technical) communication about the importance and relevance of Zoonoses and One Health to the public and policy/decision-makers, including with ministries of finance, home affairs, planning, interior, etc.

2.     All GHSA participating countries must strengthen their use of PVS in harmony with JEE and other tools in line with the targets stated in their ZDAP Road Map taking into account lessons learnt and best practices adopted in other countries.

 

V. What are best practices to be shared?

1.     Integrated zoonoses prevention and control program.

2.     Enhance of knowledge and skill among health workers and education sectors.

3.     Integrated communities empowerment through IEC.

4.     Integrated Surveillance System, outbreak investigation and reporting from Districts/Cities, Province, Central level (Avian Influenza, Rabies, Anthrax, etc.).

5.     Sentinel surveillance of zoonoses.

6.     Zoonoses Epidemiology and Laboratory Network (Four Way Linking).

7.     Expert meeting of zoonoses integrated human and animal health.

Tools, Guidelines and Best Practices Partnerships Collaborations and Outreach for 2016

a.     Emergency operations Center (EOC) and Zoonotic Disease Action Package (ZDAP) in Viet Nam

b.     Strategic Plan for the elemination of Human Rabies in Kenya 2014 -2020

c.      GHSA Projecs and Partmers in Viet Nam

d.     Frequently Asked and Quetions on Rabies

e.      Zoonosis Electronical Comic

f.       Avian Influenza Pocket Book

Intersector Coordination, Cooperation and Partnership Collaboration for Zoonoses Control  in Indonesia, 1972- 2016

1.     MOU 1972 (DG CDC MoH and DG Animal Health, MoA) : Strengthen Zoonosis Control.

2.     Three Minister Decree 1978 (Minister of : Health, Agriculture, Home Affair) : Guide line  of Rabies Control.

3.     National Comsion AI control, Pandemic Preparedness 2006 (Presidential Decree no. 7, Year  2006) : National Strategic plan of AI Control and Pandemic Influenza Preparedness, 2006.

4.     National Comission of Zoonosis Control 2011 (Presidential Decree no. 30 Year 2011) : National Strategic Plan of Integrated Zoonosis control, 2012.

ZDAP Logic Model

1.     Inputs

a.     Policy and Regulation : a. GHSA Technical Guidance Document; and b. IHR Document.

b.     Workforce and Training.

c.      Funds.

d.     Materials : a. Manuals and b. Protocols.

e.      National Partners : a. Relevant Govornment;  b. Public and Private Sectors.

f.       International Partners : WHO, FAO, OIE, World Bank, GHSA Partner Countries.

2.     Activities / Process

a.     Assessment and Planning.

b.     Framework Development and Implementation.

c.      Workforece Development.

d.     Prevention Policy.

e.      Outbreak Response.

f.       Partnership and Colaboration.

g.     Communication and Reporting.

3.     Monitoring and Evaluation

4.     Outcomes

a.     Short-term outcomes (1-3 years):

-         Health Facility,  Laboratory and surveilance system able to detect and diagnose prioritized zoonotic diseases.

-         National policy to detect, prevent and control zoonotic disease outbreak.

-         Joint outbreak response to real time zoonotic threats.

-         Animal and Public health staff trained in the implementation of one Health Approch.

b.    Intermediate outcomes (3-4 years):

-         Reduce time to detect zoonotic threats.

-         Early notification of zoonotic disease outbreak in both animal and human health sectors.

-         Innovation in prevention, detection and response of zoonotic diseases.

c.      Long-term outcomes (5 + years):

-    Avoidable zoonotic disease epidemics in animals and humans prevented.

-    Reduced impact of naturally occuring outbreaks and international or accidental release of dangerous pathogens.

6. Is there external assistance required for strengthening the Action Packages Implementation?

1.     Enhance capacity and number of human resource.

2.     Technical assisstance support (WHO and FAO) for zoonoses experties: Rabies, Pes, Leptospirosis and Antraks, etc.

3.     Strengten laboratorium capacity  for zoonoses.

4.     Research development support on zoonoses.

 

7. Key Milestones & Activities for 2016

1.     Collaboration on International Health Regulation (IHR) and Performance Veterinary Services (PVS) Training for human and animal health services.

2.     Enhance and strengthen surveillance and diagnose (early detection) of human and animal health using the existing system.

3.     Advocacy of policy and regulation on trade and production of poultry and other farm animal for national multisectoral stakeholder.

4.     Strengthen real-time bio-surveillance on animal and human implementation.

5.     Join zoonoses socialization for human and animal health workers. 

8.  Five-Year Action Items

1.     Emphasize One Health approaches across all relevant sectors of government.

2.     Implement joint IHR and PVS training programs for human and animal health services.

3.     Increase the compatibility of existing animal and human diagnostics and surveillance data fields.

4.     Introduce and develop national multi-sector policies and regulatory guidelines promoting poultry and livestock production and marketing practices.

5.     Support the implementation of national architecture for real-time bio-surveillance, spanning animal and human populations to support disease monitoring and reporting.

6.     Actively address the proposal of core competencies and systems requirements for implementation of the surveillance system.

7.     Enhance, link, and increase analytic capability within disease reporting systems, to ensure that WHO, FAO, and OIE receive pertinent information.

8.     Introduce an operational framework that supports multi-sector notification for outbreaks of suspected zoonotic origin in the early stage of emergence.

9.     Introduce systems that promote complementary research for public health purposes.

9. Closing Remark

•      One Health-driven Risk Mapping should be continued and/or expanded to help inform program direction, synergies and identify possible gaps.

Sumber :

GHSA Action Package Coordination Meeting, 23-25 August 2016, Ritz Carlton Hotel, Jakarta