DiseaseInvestigation:Course Manual/id

Investigasi Penyakit Hewan untuk Paravet

Pendahuluan

Latar Belakang

Sistim pelayanan kesehatan hewan di Indonesia merupakan salah satu bagian dari sistim kesehatan hewan nasional yang dilaksanakan oleh Pusat Kesehatan Hewan (Puskeswan) di kecamatan. Puskeswan secara kelembagaan memiliki struktur yang sesuai dengan fungsinya sebagai ujung tombak layanan kesehatan hewan, memiliki satu dokter hewan dan beberapa paravet atau petugas lapang kesehatan hewan. Mereka diharapkan mampu melakukan aktivitasnya secara efektif dan mengelola sumberdayanya secara efisien.

Investigasi penyakit merupakan salah satu tugas dari puskeswan dan SDM pengelola puskeswan harus memiliki pemahaman dan keterampilan dalam melakukan investigasi penyakit. Staf Puskeswan harus memiliki keterampilan melakukan investigasi penyakit di lapangan dan mampu memberikan informasi yang bermanfaat untuk pembuatan diagnosa dan penanganan bagi pemilik ternak. Bimtek ini merupakan acuan teknis dasar bagi staf yang melakukan investigasi penyakit. Bimtek ini mencakup kaidah teknis dan membantu investigator memahami kondisi lapangan di daerahnya.

This course was produced by a team based in South Sulawesi, through the AIP-EID Program.

Tujuan Bimbingan Teknis

Bimbingan teknis (BIMTEK) Investigasi Penyakit Hewan bertujuan untuk:

• Meningkatkan pemahaman dan kemampuan dalam menggali informasi, pemeriksaan fisik, pemeriksaan lingkungan dan pengambilan sampel yang relevan dan tepat dalam investigasi penyakit hewan di lapangan.

• Mendukung dan mendorong sistem pelaporan SMS iSIKHNAS melalui respon yang cepat dan tepat.

Tentang Buku Panduan

Buku pegangan ini memuat advis teknis dalam melakukan Investigasi penyakit. Buku ini bukan acuan yang baku dan fasilitator sebaiknya menggunakan referensi teknis pelengkap lainnya agar sesuai dengan kondisi setempat, praktek veteriner yang baik dan kemajuan ilmu pengetahuan pada umumnya.

Sebelum membawakan materi Bimtek, dinas perlu memastikan bahwa materi tersebut sesuai dengan kebutuhan peserta.

Gambaran Umum BIMTEK

BIMTEK ini dikembangkan sebagai bagian dari Program Kemitraan Australia Indonesia untuk Penyakit Menular yang Baru Muncul – Program Kesehatan Hewan. Salah satu tujuan dari Program AIP-EID adalah untuk meningkatkan kapasitas petugas lapang kesehatan hewan dalam investigasi penyakit hewan. Bimtek ini akan mengembangkan keterampilan petugas dalam melakukan investigasi penyakit di lapangan. Namun, secara khusus dapat memasukkan beberapa materi yang berkaitan dengan manajemen penyakit pilihan yang disesuaikan dengan prioritas daerah (provinsi/kabupaten/kota) dimana pelatihan akan dilaksanakan.

Pernyataan Kompetensi

Pernyataan kompetensi merupakan gambaran dari apa yang diharapkan mampu dilakukan oleh seseorang sehingga berhasil dalam melaksanakan pekerjaannya. Pernyataan kompetensi berikut menggambarkan apa yang diharapkan mampu dilakukan oleh seorang investigator.

Setelah mengikuti BIMTEK, peserta diharapkan:

• Memahami manfaat layanan kesehatan hewan bagi masyarakat

• Memahami penyakit dan prinsip-prinsip epidemiologi dalam pengumpulan informasi

• Memahami biosafeti dan biosekuriti

• Terampil dalam melakukan Investigasi penyakit hewan di lapangan, khususnya dalam hal:

• • Berkomunikasi yang baik dan efektif

• • Menggali informasi yang benar, baik dan sesuai

• • Pemeriksaan fisik yang sistematis dan menyeluruh

• • Pemeriksaan lingkungan

• • Prinsip dan praktek pengiriman sampel

• Mampu membuat sintesa dari informasi yang diperoleh (riwayat klinis, pemeriksaan fisik, pemeriksaan lingkungan, dll) dan memberikan informasi yang bermanfaat kepada peternak dan dokter hewan penyelianya

• Memahami cara-cara untuk memberikan layanan yang sangat bermanfaat bagi peternak sesuai batas kewenangan dan kapasitasnya

Investigasi penyakit: tanggung jawab investigator

Isi materi

Petugas lapang kesehatan hewan:

• Memberikan layanan kesehatan hewan pada hewan yang membutuhkan dan pemiliknya
• Memberikan advis terkait pengelolaan/pemeliharaan dan kesehatan hewan
• Membantu melakukan rujukan bila ada layanan kesehatan hewan yang tidak mampu ditangani
• Melaporkan kejadian penyakit
• Membantu dokter hewan dalam memberikan layanan kesehatan hewan dan pelaporan

Faktor-faktor yang mempengaruhi pemberian layanan kesehatan hewan yang baik:

• Kecepatan petugas dalam memberi tanggapan terhadap keluhan klien atau peternak
• Keandalan (pengetahuan, pengalaman dan keterampilan) petugas lapang kesehatan hewan dalam memberikan layanan berupa pencegahan dan penanganan penyakit
• Klien atau peternak membayar biaya layanan. Seringkali karena keterbatasan obat dan alat di dinas, maka petugas lapang kesehatan hewan akan memungut bayaran untuk layanannya. Biaya tersebut dapat membuat peternak enggan untuk mencari layanan.
• Pemahaman klien tentang pelayanan yang akan diterimanya
• Biaya program pengendalian penyakit – pemusnahan hewan, pembatasan lalu lintas

Tugas investigator:

Merespon dan menginvestigasi laporan dari pelapor desa atau masyarakat peternak dalam layanan kesehatah hewan

• Melakukan koordinasi dengan dokter hewan dan petugas lain yang terlibat dalam investigasi
• Membangun komunikasi dengan pemilik ternak
• Menggali informasi penting dari peterak ataupun sumber lainnya
• Melakukan pemeriksaan fisik pada hewan
• Melakukan pemeriksaan lingkungan
• melakukan pengambilan dan penanganan sampel
• memberikan advis kepada pemilik dan/atau penanganan pada hewan
• Mengelola informasi dan melaporkan hasil investigasi

Melaporkan hasil/temuan investigasi melalui sistem informasi

Investigasi penyakit biasanya dilakukan untuk merespon laporan penyakit. Prosedur pelaporan dibahas dalam modul pelsa dan module dinas – di sini. Investigator mampu merevisi/menambahkan informasi kasus penyakit sesuai hasil investigasi.

Menyadari bahwa terdapat peraturan perundangan RI yang mencakup kegiatan veteriner dalam pelaksanaan investigasi penyakit

PERATURAN MENTERI PERTANIAN NOMOR : 83/Permentan/OT.140/12/2012 TENTANG PEDOMAN FORMASI JABATAN FUNGSIONAL MEDIK VETERINER DAN PARAMEDIK VETERINER

1. Paramedik Veteriner adalah Pegawai Negeri Sipil yang diberi tugas, tanggungjawab, wewenang dan hak secara penuh oleh Pejabat berwenang untuk membantu Medik Veteriner dalam melakukan kegiatan pengendalian dan penanggulangan hama dan penyakit hewan serta pengamanan produk hewan dan pengembangan kesehatan hewan.

2. Medik Veteriner melaksanakan tugas-tugas berikut, dibantu oleh paramedik veteriner:

• Melakukan pelayanan penyidikan dan pengujian veteriner;

• Melakukan pengujian mutu dan sertifikasi obat hewan;

• Melakukan pengujian dan produksi vaksin dan bahan biologik;

• Melakukan pengujian kesehatan dan keamanan produk peternakan;

• Melakukan pengujian keamanan pakan ternak;

• Melakukan pengujian kesehatan semen dan embrio;

• Melakukan pelayanan kesehatan bibit ternak.

• Melakukan pengamatan dan pengidentifikasian penyakit hewan;

• Melakukan pengamanan penyakit hewan;

• Melakukan pencegahan penyakit hewan;

• Melakukan pemberantasan penyakit hewan;

• Melakukan pengawasan obat hewan;

• Melakukan pengendalian penanggulangan zoonosis pada hewan;

• Melakukan penjaminan keamanan dan kesehatan produk hewan;

• Menerapkan prinsip-prinsip kesejahteraan hewan.

Prinsip-prinsip Dasar Terjadinya Penyakit

Latar belakang

Seorang petugas lapang yang memberikan layanan kesehatan hewan berupa investigasi penyakit mungkin menyangka bahwa agen biologis seperti bakteri, virus atau parasit itu sendiri dapat menyebabkan penyakit. Namun, penyebab-penyebab non infeksi juga ada seperti racun, trauma, nutrisi dan stres yang diakibatkan oleh cara pemeliharaan. Agen yang sama tidak selalu menghasilkan tanda klinis yang sama pada hewan atau lingkungan yang berbeda. Petugas lapang sebaiknya mempertimbangkan hubungan antara agen, inang dan lingkungan. Konsep ‘segitiga epidemiologi’ dapat membantu menggambarkan hal ini. Segitiga ini mengaitkan agen, inang dan lingkungan.

Tujuan pembelajaran

• Peserta mampu menjelaskan aspek-aspek penting terjadinya penyakit dengan mengacu pada segitiga epidemiologi.
• Peserta mampu menjelaskan agen atau penyebab penyakit dalam prinsip dasar terjadinya penyakit.
• Peserta mampu menjelaskan konsep penularan penyakit.

Isi materi

Penyakit: Penyakit merupakan suatu kondisi yang mempengaruhi fungsi normal tubuh. Ada yang menular seperti brucellosis, rabies atau tidak menular seperti trauma, kanker atau keracunan. Tanda-tanda klinisnya mungkin terlihat, tidak terlihat dan akibatnya bisa beragam mulai dari keluhan ringan hingga kematian.

Berdasarkan kemampuannya berpindah ke individu yang lain, penyakit menular dapat pula dikelompokkan menurut sifatnya. Ada penyakit yang menular secara langsung (contagious) dari satu individu ke individu lainnya – misalnya penyakit mulut dan kuku, influenza. Ada pula yang menular secara tidak langsung seperti Japanese encephalitis (nyamuk), babesiosis (kutu), anthraks (tanah yang terkontaminasi). Namun, beberapa penyakit seperti anthraks dan influenza dapat menular secara langsung maupun tidak langsung.

Konsep segitiga epidemiologi menggambarkan hubungan antara inang, agen dan lingkungan dalam kejadian penyakit. Interaksi dari ketiga komponen segitiga epidemiologi dapat mempengaruhi proses terjadinya penyakit. Beberapa dari komponen tersebut – umumnya agen, tetapi terkadang lingkungan atau inang serta komponen lainnya juga ‘perlu’ ada untuk dapat menyebabkan penyakit.

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Segitiga epidemiologi

Inang merupakan hewan yang rentan. Komponen inang meliputi spesies, ras, jenis kelamin, umur, kondisi fisik, imunitas, termasuk status vaksinasi atau faktor-faktor spesifik inang lainnya.

Agen merupakan salah satu komponen penyebab penyakit yang terbagi atas agen-agen biologis dan non biologis. Agen biologis diantaranya virus, bakteri, jamur/fungi, endoparasit dan ektoparasit. Agen non biologis meliputi bahan kimia dan racun.

Lingkungan dapat mempengaruhi keadaan inang dan/atau agen sedemikian rupa sehingga turut mempengaruhi proses terjadinya penyakit. Komponen ini meliputi ketinggian, geografis, iklim, musim, kelembaban, debu, sinar matahari, kandang, juga termasuk sistem pengelolaan, pemeliharaan dan kepadatan populasi. Komponen ini secara lengkap dibahas dalam Bimtek Epidemiologi Lapangan.

Bagaimana agen biologis/jenis patogen berbeda menyebar? Berikut contoh proses penyebarannya:

• Menghirup tetesan aerosol (influenza, tuberculosis, PMK, anthraks)
• Mengkonsumsi pakan atau air yang terkontaminasi, tangan yang kotor, kontak oral (brucellosis, parasit nematoda, penyakit sapi gila, anthraks)
• Mekanis, masuknya agen melalui kulit yang rusak/luka atau melalui mukosa (leptospirosis, rabies, anthraks)
• Vektor, melalui gigitan serangga atau kutu (demam caplak (tick fever), Japanese encephalitis (JE), penyakit lidah biru (bluetongue), demam tiga hari (BEF))
• Iatrogenik – terkait dengan penanganan seperti teknik aseptik yang buruk (human immunodeficiency virus, methicillin resistant Staphylococcus aureus). Sejumlah penyakit dapat ditularkan selama proses inseminasi buatan
• Seksual - melalui kelamin atau penularan secara seksual (human immunodeficiency virus, infectious pustular vulvovaginitis, classical swine fever, bovine campylobacteriosis)
• Vertikal, ke janin dalam rahim (transmisi vertikal) (Salmonella Enteritidis (unggas), human immunodeficiency virus)

Pra investigasi

Koordinasi, konfirmasi dan persiapan sebelum ke lapangan

Latar belakang

Sebelum merespon laporan baik dari pelapor desa maupun dari masyarakat, para investigator tentu harus mempersiapkan diri. Mereka adalah bagian dari sistim kepemerintahan, secara struktural dan administrasi, di kabupatennya. Oleh karena itu, sebelum melakukan respon atau investigasi ke lapangan, mereka perlu berkoordinasi dengan puskeswan ataupun atasan langsungnya sebelum melakukan respon atau investigasi lapangan. Laporan dari pelsa maupun masyarakat peternak juga perlu dikonfirmasi lebih dalam agar setelah tiba di lokasi proses pelayanan dan investigasi dapat berjalan lebih optimal. Sebelum ke lapangan, pastikan lokasi pelapor, ternak yang dilaporkan dan ketersediaan waktu.

Persiapan merupakan bagian penting dari investigasi. Seringkali persiapan yang tidak optimal dapat berdampak pada hasil investigasi. Pastikan sejumlah peralatan yang dibutuhkan selama proses investigasi di lapangan tersedia, misalnya alat pemeriksaan/penilaian hewan, pengambilan sampel, penanganan, biosecurity/biosafety, logistik dan alat tulis-menulis.

Tujuan pembelajaran

• Peserta mampu menjelaskan jalur koordinasi secara struktural dan administrasi sesuai kondisi daerahnya masing-masing.

• Peserta mampu menjelaskan pentingnya melakukan konfirmasi atas laporan kejadian kasus dari lapangan.

• Peserta mampu menyebutkan/membuat daftar alat dan bahan yang dipersiapkan sebelum melakukan investigasi di lapangan.

Isi Materi

Koordinasi dan konfirmasi

• Masing-masing dinas dan kabupaten biasanya memiliki struktur koordinasi yang berbeda disesuaikan dengan kebutuhan, kebijakan dan kebiasaan setempat. Proses tersebut umumnya dimulai ketika masyarakat melaporkan kasus penyakit. Ada yang berkoordinasi sesama petugas lapang, pada tingkat puskeswan, kepala seksi atau bahkan hanya sampai ke tingkat bidang atau eselon 3. Namun demikian, banyak juga jalur koordinasi ini tidak berjalan, biasanya koordinasi dilakukan saat ada penyakit yang dicurigai PHMS atau wabah atau minimal setelah petugas lapang melakukan pelayanan.

• Konfirmasi diperlukan ketika seorang petugas lapang mendapatkan laporan dari pelsa atau sistim informasi kesehatan hewan yang ada. Hal ini dilakukan untuk memastikan laporan tersebut, lokasinya, pemilik ternak dan tanda klinis yang dilaporkan. Informasi yang diperoleh akan menjadi dasar persiapan investigasi, misalnya mempersiapkan peralatan pengambilan sampel, pemusnahan (disposal), alat pelindung dan desinfektan.

• Bagian akhir dari kegiatan investigasi adalah melaporkan informasi yang diperoleh, seperti tanda klinis, kemungkinan diagnosa, penanganan dan advis yang diberikan

Persiapan

• Membuat daftar, memahami fungsi dan menyiapkan peralatan yang dibutuhkan oleh investigator untuk melakukan pemeriksaan fisik terhadap hewan yang sakit
  • Alat untuk melakukan restraint misalnya halter, kandang jepit, tali
  • thermometer
  • Jam atau pencatat waktu untuk denyut nadi & pernapasan
  • buku catatan dan pulpen untuk mencatat hasil temuan (cobalah untuk menekankan pentingnya pencatatan secara sistematis)

• Membuat daftar, memahami fungsi serta menyiapkan peralatan dan bahan habis pakai yang dibutuhkan untuk mengambil sampel dari hewan yang sakit
  • Pisau, gunting, pinset, pisau bedah, sarung tangan
  • Jarum (ukuran jarum berbeda untuk tujuan yang berbeda)
  • syringes
  • Tabung darah/vacutainers – darah (tutup merah) untuk serum, EDTA (tutup ungu) untuk darah/plasma
  • Kapas, tisu alcohol, dll?
  • Media sampel dan pengangkut
  • Penanganan

• Memahami dan menyadari fungsi alat pelindung diri (APD): Coverall sekali pakai, apron, pembungkus sepatu, sarung tangan , masker wajah, tas ‘limbah’, tisu alkohol. APD lengkap tidak selalu tersedia atau dibutuhkan.

• Kebutuhan alat pelindung bervariasi menurut kondisi dan terkadang yang dibutuhkan hanya alat pelindung sederhana seperti coverall yang dapat digunakan kembali, desinfektan dan sarung tangan.

Daftar persiapan (checklist) investigasi

Equipment	Checkmark	Remarks
Peralatan Pemeriksaan fisik: Stetoskop Thermometer Senter Alat lainnya	o o o o	Stetoskop hanya untuk drh Disesuaikan dengan informasi yang diperoleh
Persiapan pengambilan sampel Tabung venoject tanpa koagulan Tabung venoject dengan koagulan Jarum venoject Holder/pemegang jarum Plastik flip (wadah sampel) Gunting Pinset Gelas obyek Label Tissue Kontainer pembawa sampel	o o o o o o o o o o o	Dll
Persiapan pemeriksaan lapangan Rapid tes	o
Persiapan alat pelindung diri Sarung tangan Masker Sepatu Boot Apron Desinfektan Antiseptik Plastik disposal	o o o o o o o	As required

Biosecurity dan biosafety (Perlindungan diri)

Latar belakang

Petugas lapang kesehatan hewan dalam menjalankan tugasnya di lapangan sering tidak menyadari bahwa dirinya dapat menjadi agen yang menyebabkan penyakit hewan, misalnya anthraks, brucellosis, leptospirosis. Ancaman yang dimaksudkan berupa penularan penyakit zoonosis yang bersumber dari hewan. Petugas harus memahami resiko tersebut dan memahami prinsip-prinsip biosekuriti dan biosafeti yang dapat memperkecil resiko penularan. Perlindungan diri dari ancaman penyakit bagi investigator saat memberikan pelayanan senantiasa harus dipertimbangkan. Prinsip-prinsip biosekuriti harus diketahui dan ditaati guna meminimalisir resiko perpindahan atau penyebaran penyakit hewan. Penerapan prinsip-prinsip biosekuti dan biosafeti sederhana oleh petugas lapang dapat menjadi kebiasaan baik yang dilakukan setiap kali memberikan pelayanan.

Tujuan pembelajaran

• Peserta mampu menjelaskan konsep dasar biosekuriti, baik prinsip, faktor risiko dan peralatan.
• Peserta mampu menjelaskan manfaat perlindungan diri berdasarkan konsep biosafety.
• Peserta mampu menjelaskan prinsip penggunaan biosekuriti dan biosafeti, termasuk pembersihan dan desinfeksi di/di luar lokasi.

Isi materi

Pengantar biosecurity (video tersedia)

a. Pengertian: Serangkaian tindakan untuk mencegah masuk, berkembang dan menyebarnya agen penyakit dari dan ke peternakan.

b. Prinsip

• Mencegah masuknya agen penyakit
• Mencegah berkembangnya agen penyakit
• Mencegah menyebarnya penyakit

c. Faktor resiko

• Orang/ manusia
• Barang/ peralatan
• Hewan
• Serangga/rodensia/hewan liar
• Air
• Pakan

Faktor resiko perlu dipertimbangkan dan ditangani dengan baik. Sebagai contoh, flu burung memiliki tingkat penularan tinggi, sementara tetanus memerlukan kondisi khusus untuk menular. Akibat yang ditimbulkan juga penting untuk diperhitungkan. Beberapa penyakit seperti rabies, tidak umum, tetapi selalu menyebabkan kematian pada mamalia yang tidak divaksin.

d. Elemen

• Kebersihan/sanitasi

Pembersihan dan desinfeksi kandang, peralatan, kendaraan maupun pekerja yang masuk dan keluar wilayah peternakan atau lokasi kejadian penyakit secara teratur, termasuk peralatan yang digunakan selama dan pasca investigasi seperti spuit, alat uji dan sebagainya.

• Isolasi

Menciptakan dan menjaga lingkungan dimana hewan terlindungi dari agen penyakit atau yang berpotensi membawa penyakit (carrier) seperti hewan, manusia, pakaian dan peralatan, udara, air, pakan yang terkontaminasi. Perlindungan dari vektor –caplak, lalat, nyamuk perlu pertimbangkan untuk sejumlah penyakit.

• Pengendalian lalu lintas/pergerakan

Mengendalikan lalu lintas manusia, hewan, peralatan dan kendaraan yang masuk dan keluar peternakan serta tidak mengijinkan orang dan kendaraan yang tidak berkepentingan memasuki daerah peternakan.

• Pembagian zona

Zona biosecurity ditetapkan sesuai faktor resiko penularan penyakit terhadap hewan lain atau petugas (zoonosis). Resiko penularan mungkin tinggi atau rendah.

e. Contoh pelaksanaan biosecurity

• Mencuci tangan dengan sabun, mandi dan mencuci pakaian setelah menangani hewan
• Melakukan pembersihan dan desinfeksi (semprot, dipping) untuk seluruh barang, terutama kendaraan yang akan memasuki wilayah peternakan
• Melakukan penyemprotan kandang dengan insektisida pembasmi hama, akarisida atau desinfektan pada tempat yang telah ditentukan
• Membuang dan membakar sampah medis setelah melakukan investigasi di lokasi kejadian
• Membatasi penularan penyakit akibat mobilitas pegawai dan menjaga agar tidak setiap orang dapat bebas keluar masuk wilayah peternakan sebab hal tersebut dapat memungkinkan terjadinya penularan penyakit.
• Membakar atau mengubur bangkai ternak yang mati karena penyakit, khususnya penyakit menular
• Menyediakan fasilitas desinfeksi untuk staf/karyawan
• Segera mengeluarkan ternak yang mati dari kandang untuk dikubur atau dimusnahkan oleh petugas yang berwenang
• Sapi yang mati mendadak, disertai dengan pengeluaran darah dari lubang kumlah, BANGKAINYA TIDAK BOLEH DIBUKA
• Memisahkan dan mengatur kandang sapi dewasa, sapi dara dan anak sapi
• Ternak sapi yang baru datang atau akan memasuki peternakan ditempatkan dalam kandang karantina untuk diamati
• Menerapkan cara beternak yang tepat, misalnya sapi Bali tidak dipelihara dengan domba karena dapat menyebabkan penyakit ingusan (MCF), sebuah penyakit yang berbahaya untuk sapi Bali.
• Memisahkan hewan sakit dari yang sehat, mengelompokkan berdasarkan spesies dan umur
• Merawat hewan yang sakit
• Membersihkan dan membuang kotoran secara teratur
• Melakukan vaksinasi pada hewan
• Beternak yang baik, hewan tidak stres, diberikan nutrisi yang baik dan air bersih

Biosafety (Perlindungan diri)

a. Pengertian: merupakan kondisi dan upaya untuk melindungi diri dari pencemaran agen penyakit.

b. Manfaat perlindungan diri

Memberikan jaminan keamanan pada diri petugas dari bahaya pencemaran agen penyakit saat melakukan investigasi penyakit di lapangan.

c. Prinsip biosafety dan pencegahan penularan penyakit perlu mempertimbangkan:

• APD lengkap tidak selalu tersedia atau dibutuhkan.

• Kapan APD digunakan, hal ini terkait dengan waktu dan peralatan yang tepat - Biosafety sebelum berangkat ke lokasi dan saat berada di lokasi dapat mengurangi resiko pencemaran agen penyakit terhadap petugas. Petugas sebaiknya melindungi badan, mata, pernafasan, kulit, tangan dan kaki mereka.

Alat pelindung sebaiknya digunakan sesuai kebutuhan. APD lengkap hanya dibutuhkan ketika menghadapi resiko tinggi dan terdapat dugaan agen penyakit zoonosis. Kontaminasi agen penyakit dan resiko yang dihadapi oleh operator dapat dikurangi dengan melakukan tindakan pencegahan sederhana.

• Hal-hal yang perlu dilakukan sebelum meninggalkan lokasi

Setelah petugas selesai bekerja, peralatan yang digunakan harus dibersihkan atau dimusnahkan/disposal (termasuk peralatan dan bahan-bahan medis untuk investigasi antara lain sisa kapas, spuit, vacutainer, dll.). Resiko dapat diatasi dengan pembakaran, autoklaf atau penggunaan desinfektan yang tepat untuk bahan-bahan yang telah digunakan, tangan langsung dibilas dengan desinfektan dan sabun di bawah air yang mengalir. Pelanggaran prosedur biosekuriti perlu dicatat dan diperhatikan oleh investigator. Contoh-contoh pelanggaran biosecurity/biosafety:

• Seorang investigator memasuki kandang ayam dan menemukan 50% dari ayam-ayam tersebut mati dan yang lainnya banyak yang mengalami stres. Ia melakukan investigasi, mengambil sampel dan dalam perjalanan pulang, ia singgah di peternakan ayam lainnya untuk menanyakan kondisi ayam-ayam di sana.

• Seorang investigator dihubungi untuk menangani kasus kematian mendadak pada sapi. Ia memenuhi panggilan tersebut dan menemukan dua dari empat sapi (satu sapi betina dewasa, satu anak sapi) mati dan satu sapi lainnya memiliki suhu tubuh tinggi. Ia memutuskan untuk melakukan post mortem pada anak sapi yang mati dan melangkah di atas cairan yang berasal dari kegiatan post mortem. Ia kemudian melakukan pemeriksaan klinis pada sapi yang menderita demam, mengumpulkan riwayat dan kembali ke kantor dengan sepeda motornya untuk melapor.

• Sejumlah petugas kesehatan hewan terlibat dalam sebuah program vaksinasi untuk mengendalikan brucellosis pada sapi. Vaksin brucellosis diberikan dalam botol-botol multidosis. Seorang petugas vaksinasi, saat mengisi spuitnya, secara tidak sengaja menimbulkan cipratan dari jarum dan mengenai wajahnya yang berada dekat dengan dua petugas lainnya. Ia membersihkan cipratan tersebut dari wajahnya tanpa memberitahu yang lain tentang kejadian tersebut. Kemudian diketahui bahwa sebuah botol yang seharusnya berisi 10 dosis ternyata berisi vaksin yang hanya cukup untuk digunakan pada 8 sapi. Dua atau tiga minggu kemudian, dua orang operator mengalami sakit kepala dan demam. Dokter meresepkan obat analgesik untuk mereka.

Latihan: Apa yang terjadi pada setiap kasus tersebut? Pada kasus terakhir, apakah dokter melakukan investigasi penyakit dengan baik?

Gambar untuk studi kasus – pikirkan tentang resiko yang dapat ditimbulkan oleh inseminator, peralatan, sarung tangan, lingkungan berikut alasannya.

Investigasi penyakit hewan di lapangan

Komunikasi yang Efektif

Latar belakang

Saat melakukan investigasi kejadian penyakit, informasi diperoleh melalui percakapan dengan masyarakat dan pengamatan/pemeriksaan yang dilakukan sendiri. Keterampilan berkomunikasi sangat dibutuhkan agar informasi yang baik dapat diperoleh ketika melakukan investigasi penyakit. Dalam konteks ini, investigator akan berfokus membahas komunikasi yang efektif dan keterampilan untuk mengajukan pertanyaan yang tepat.

Tujuan pembelajaran

• Peserta mampu menjelaskan konsep komunikasi yang efektif untuk investigasi penyakit.
• Peserta terampil menggunakan jenis-jenis pertanyaan yang berbeda.

Isi materi

Komunikasi merupakan proses pertukaran informasi yang bermakna antara beberapa orang atau sekelompok orang. Proses ini dapat berlangsung secara verbal melalui ucapan atau tulisan, secara visual menggunakan gambar, grafik atau dengan perilaku melalui gerakan atau bahasa tubuh menggunakan gestur-gestur non verbal. Perpaduan dari seluruh kegiatan ini akan selalu ada dan setiap individu memberikan respon yang berbeda untuk setiap kegiatan tersebut. Komunikasi yang baik adalah proses dua arah dimana mereka yang terlibat bebas untuk mengajukan pertanyaan, memberikan tanggapan dan jawaban.

Klien dalam bidang kedokteran hewan (veteriner) adalah seluruh masyarakat peternak (perorangan/kelompok) maupun yang bukan peternak tetapi memiliki atau memelihara hewan ternak atau memiliki minat untuk memelihara atau kepedulian terhadap hewan ternak.

Dalam konteks jasa veteriner, hewan disebut pasien dan pemilik hewan yang dilayani disebut sebagai klien. Hubungan pemilik dengan ternaknya penting untuk dipahami agar komunikasi antara pemberi dan penerima layanan dapat berlangsung baik.

Petugas kesehatan hewan bertanggung jawab kepada pimpinan mereka sehingga informasi yang diperoleh perlu disampaikan/dilaporkan melalui sistem kesehatan hewan. Informasi tersebut dapat dilaporkan atau disampaikan dengan mengirimkan SMS ke iSIKHNAS. Jika belum memiliki iSIKHNAS, informasi dapat disampaikan melalui sistem pelaporan yang ada.

Persepsi Masyarakat terhadap ternaknya

Masyarakat memiliki pandangan yang berbeda tentang ternak, tergantung alasan mereka memilihara ternak:

• Pangan dan nutrisi: hewan merupakan sumber pangan yang sangat penting [protein]

• Fungsi sosial: hewan dapat mengangkat status social pemiliknya. Hewan dapat berkontribusi terhadap kesetaraan gender sebab memberikan peluang bagi perempuan untuk memiliki ternak. Di sejumlah kalangan masyarakat, hewan memiliki peran dalam praktek-praktek keagamaan atau budaya.

• Kontribusi terhadap produksi pertanian: tenaga dan kotoran hewan dapat digunakan untuk meningkatkan kesuburan tanah

• Sumber pendapatan dan peningkatan kesejahteraan: hewan dapat meningkatkan kesejahteraan serta memberikan rasa aman sebab hewan dapat berfungsi sebagai ‘rekening bank’ dan ‘polis asuransi’

• Peran ekonomi: produksi hewan dapat menjadi bagian penting dari perekonomian lokal dan regional

• Ternak dan lingkungan: produksi ternak merupakan bagian dari pemanfaatan lahan secara berkelanjutan. Meski demikian, produksi hewan dapat memberikan dampak positif sekaligus negatif terhadap lingkungan

• Penyangga resiko: Di sejumlah kalangan masyarakat, produksi hewan memberikan sumber pendapatan alternatif yang berfungsi sebagai penyangga dalam menghadapi resiko gagal panen.

Pelayanan yang baik selalu berorientasi pada kepuasan klien atau pelanggan. Untuk dapat memberikan pelayanan yang baik, kita harus memahami klien dan kebutuhannya.

Investigator perlu mengetahui harapan dan (kurangnya) motivasi klien untuk melaporkan kebutuhannya akan layanan:

• Budaya – mungkin sebelumnya menggunakan penyembuh tradisional/dukun; mungkin tidak cocok dengan obat-obatan dari ‘Barat’, teori kuman, dll; mungkin tidak mempercayai ‘orang asing’ dari luar desa

• Finansia – mungkin tidak dapat menjangkau pelayanan kesehatan hewan; penyembuh tradisional (dukun) atau obat herbal mungkin lebih murah;

• Individual – mungkin memilih mengobati sendiri berdasarkan pengalaman mereka sebelumnya; mungkin pernah mencoba pelayanan kesehatan hewan sebelumnya namun tidak puas; mungkin terlalu malu untuk menghubungi pelayanan kesehatan hewan

Agar klien dapat mengakses layanan, seorang petugas lapang sebaiknya memperluas hubungan dan mempromosikan dirinya dengan:

• Berkomunikasi secara rutin dengan anggota masyarakat, misalnya melalui pertemuan rutin, memperbaharui informasi, menghubungi dan menjawab panggilan telepon
• Memasang papan penanda yang dapat terlihat dengan jelas
• Membagikan kartu nama
• Memberikan layanan berkualitas untuk peternak, merespon laporan penyakit, memberikan diagnosa ilmiah serta perawatan (mereka datang, ternaknya dirawat dan kondisinya lebih baik)
• Secara kreatif, dapat disesuaikan dengan kondisi sosial-budaya dan potensi

Animal health officers (paravets) must understand the way people view their livestock so they can approach their "clients." Good understanding about "clients" will help "communication" during investigation or while performing other duties for collecting information.

Principles of effective communication 

Communication is priority skill required for collecting information during disease investigation. The importance of two way communication should be emphasized. The principles of effective communication include Respect, Empathy, Audibility, Clarity and Humility

Respect

• Respect means positive feelings or respect to interlocutors. Everybody wants to be appreciated and respected and that is part of individual needs.

• In his book, "How to Win Friends and Influence People", Dale Carnegie explained that the biggest secret in dealing with humans is honest and sincere appreciation. This principle of respecting others must always be applied in communication.

Empathy

• Empathy is an ability to place yourself in a situation or condition faced by others.

• Showing empathy means placing ourselves as good listeners, even before people start listening to us.

• Understanding proper time for communicating is also a form of empathy.

• Examples of empathetic response:
  • Repeating word by word
  • Paraphrasing message content
  • Reflecting feeling
  • Audible
  • Eye contact

Audibility means the messages are heard. What should one do?

• Messages can be understood using simple language combined with speaking clearly. Avoid using language unfamiliar to interlocutors.
• Convey important messages only. Simplify the message. Speak right to the point. People do not need indirect language.
• Use body language. Eye-contact, hand movement and body position are easily understood by your interlocutors.
• Use examples and illustrations. Analogies are very helpful in delivering messages.

Clarity

• Clarity means clearness of the messages that we deliver. One reason that triggers misunderstanding between one person with another is unclear information.

Humility

• Humility does not mean low self-esteem. A humble person allows others to speak first and is a good listener.

Techniques for posting effective questions

• Asking the right question is the heart of effective communication and information exchange.

• Generally, a simple guide for making question is 5W + 1H (what, who, when, where, why and how) or in Indonesian acronym "MENGAPA SI AKA DIBA?"

• Asking the right questions in certain situation allows us to improve various communication skills, such as:
  • Able to collect better information and learn more,
  • Able to build stronger relationship,
  • More effective in managing people and helping others to learn as well.

Open question technique

• used for collecting broader information
• usually start with what, why and how
• allows respondent to give broad answers.

Examples of open questions:

• What is your livestock problem?
• Can you explain how you rear your livestock?
• Why do you think they are sick?

Closed question technique

• generally provides limited options for response

Some examples of closed questions:

• Have you fed your livestock?
• Do they refuse to eat?

Probing question technique

• usually open questions

• directed to encourage respondent to improve response quality and quantity.

• used for getting more detailed information about something or simply for understanding statement/s made by respondent.

• good for clarifying a story or information comprehensively and to collect information from somebody who provides limited information.

Examples of probing questions:

• Did you see something before it died?

• What did you mean by poisoned?

• What do you think about giving worm medicine to your cattle?

• Can you explain how to make a halter for livestock?

Taking a case history

Background

The essence of disease investigation is information collection. The aim is to collect factual relevant information for investigation. The paravet should appreciate any information provided by farmer, no matter how small the information is. The information could be subjective or objective depending on the investigator"s skills in asking questions to obtain accurate and reliable information. Proper and relevant information helps the veterinarian to reach a diagnosis. Information to collect includes current disease history, past disease history, herd or group disease history and environment history. Comprehensive recording of that information is needed for analyzing and making conclusions.

Learning objective

• Participants can explain 4 histories (current, previous, herd, environment) to collect while conducting disease investigation in the field.

• Participants are skillful in asking questions to get the 4 histories for disease investigation.

Content

Exploring or digging information based on the systematics of:

• Previous Disease History
• Current Disease History
• Herd Disease History
• Environmental and social community histories related with the livestock management system

Definition of exploring information or history

Exploring case history requires thorough techniques to obtain information about the case history so that information obtained can provide a complete and comprehensive description. Make sure that previous history includes the previous herd and environment histories (traceback).

In exploring the case history, investigators should be able to make questions list based using 5W (Who, What, Where, When, Why and in some cases, How). Some examples are:

Who? (animal): the questions cover individual or group.

Example: what animal(s) are sick? Breed? Age? Sex? Number?

What? What is wrong? Were there any similar things in the same cattle previously or in other cattle in the same area?

Example: what are the abnormal signs that can be observed? May include specific questions about behaviour, diet, appearance

Where? Where are/were the animals when the condition was first noticed?

Example: Where? is the location (the address) of the disease incident, the enclosure/pasture or the address of the farmer? Where do they graze their cattle? etc.

When? The questions related with the time of occurrence and progression of the event(s).

Example: when did the paralysis occur in the cattle? If there is any, when did it recur eg. at the planting period or at the beginning of rainy season? When were problems first seen?

Why? the questions to support or strengthen the information. Usually, to find out the risk factors towards the disease.

Example: Why are these chickens always at this end of the shed? Why do you use short ropes to tie your cattle?

How? the questions regarding with the disease incidence process related with the farm management system or habits of society.

Example: How are cattle raised in that area? When the farmer provides information. Answers to questions like may not add to the relevant disease related information.

Conduct a systematic information exploration, including:

Current Disease History (RPS -Riwayat penyakit yang sekarang)

The main complaint or illness is the illness that makes farmers (owners) visiting animal health service station asking for help, for instance: bloat, gasping, cough, refuse to eat, diarrhea, etc. Main illness should not be more than one. After revealing the main illness, ask the following questions systematically:

Ask about the animal's activities such as:

• How is their appetite?

• Faeces? Colour? Consistency?

• Is/was there any fever, cough, or limp?

• How about cattle condition, thin, medium size or fat?

• Is there any weight loss?

• Have you given any treatment - what is the response?

• Which part of the animal body showed signs of illness?

• When did the illness start or how long it has been occurring?

• Did it occur suddenly or gradually?

• What about behaviour changes? (such as keep making noises, moving legs, breathing, etc)

• Are there any other affected livestock?

• Is the animal body condition worse because of the disease or not?

• Have you tried to help their sick cattle, such as moving the cattle position to right or left side, etc.

Previous Disease History (RPD - Riwayat penyakit dahulu)

Ask whether any of his/her animals once got the same illness or not, when and how many time did it happen? What sort of medicines given? Search for disease relevant with current condition and chronic disease, such as:

• Have the cattle been vaccinated previously or not

• Have you seen the same clinical signs before?

• Have you give worm medicine or other medicine to your cattle?

• How was goat condition at that time? Etc.

Herd Disease History (RPK - Riwayat penyakit dalam kelompok)

Herd history is important in identifying occurrence of infectious disease in herds. Some diseases may transmit and spread rapidly as the consequence of farm management and the nature of very contagious diseases.

• Are there other sick animal in this or nearby areas or herds?

• When the clinical signs start to occur?

• Has the sick animal received any treatment?

• How is the condition of the sick animal currently?

• Have there been new chickens introduced to the cage? etc

Environmental and social community histories (RLS - Riwayat lingkungan sosial)

To evaluate farmer"s social status which is relevant with farming method, fodder supply, pasture and the surrounding environment as well as community activities at certain season. This question aims to identify the possibility of disease occurrence due to management.

• Where do farmers graze their cattle?

• Where do the farmers provide food and drink for chickens?

• Where are they housed?

• Is it planting or harvesting season or farmers using herbicides or insecticide?

• Is there any conditions or certain times of gathering or moving cattle to other areas?etc

KEY WORDS FOR CASE STUDY

Explore information about the diseases histories based on the RPS, RPD, RPK, RLS systematics. Develop a question list for the case

Things to be noted in taking a case history:

1. Allow farmers to tell about their cattle problems using their own words.

2. Use open and closed questions. Start with open questions first, followed by closed questions.

3. Listen carefully. Give farmers opportunity to complete the story and do not interrupt.

4. Use concise easy to understand questions. Avoid using medical terms which are not understood by farmers.

5. Regularly, make summary of farmers' statements to verify your understanding. Ask farmers to correct your statement or ask them to provide additional information if it is required.

6. Develop a time sequence of an incident.

7. Take notes that can be referred to when providing information to others

Physical examination

Background

Physical examination aims to obtain objective information. It is important to clarify the information received previously, in particular to check the condition of the sick animal. In conducting a physical examination, the investigator should at least have basic understanding about animal anatomy and physiology. They should also have the knowledge about normal condition. In this context, an investigator is not expected to become an expert in conducting a physical examination, but should understand and apply a routine and systematic approach to physical examination and be able to note significant changes from normal.

Learning objective

• Participants can conduct a basic physical examination.
• Participants can describe possible changes from normal noted during physical examination

Content

Technique of physical examination in an animal should have a body systems approach. Once learned, it should be repeated regularly so that each body system is examined to the extent that any variation from normal can be detected. Repetition encourages habit and makes clinical examination more reliable. The system described here is adapted to skills of participants. The description is given in the context of large animals, but the same principles apply for pet animals and poultry.

Physical examination includes:

• Behaviour - bright, depressed, normal reactions on approach. These signs should be observed before restraining the animal

Conduct observation and seek out for information from the carer of the animal. Obtain as much information as possible, but be aware that answers may not be correct. Check reactions to stimuli e.g. loud noises, movement, reaction to other animals.

• General appearance, including body condition, look for swellings, lumps, indications of trauma.

A healthy animal has good appetite. A sick animal may have a reduced appetite or it may not eat at all. Evidence of defecation and urination can be looked for at this stage and respiratory rates and often heart rate can be taken without approaching and disturbing the animal. Skin condition can be checked and quiet observation or gentle "driving" may reveal gait abnormalities and lameness.

• Skin and Fur: A healthy animal has clean and well groomed fur, it may be rough or smooth as a breed characteristic. Its skin is smooth, no lesions or scabs found. Dull, dry-look, dirty and ragged hair may be signs of less healthy animal.

• Temperature

Temperature examination, to determine or measure body temperature of an animal through rectum using digital or mercury thermometer as the tool. To avoid effect of stress on temperature, this should be done as early as possible.

• Restrain the animal
• Stand beside hind leg
• Lift tail, insert thermometer into rectum at least 5cm.
• Allow one minute for mercury thermometer, or follow instruction for digital thermometer (usually until "beep")
• Remove, record result and clean thermometer

Normal body temp degC

Animal	Av temp	Increased
Cattle	38,5	39.5
Sheep	39	40
Goat	39,5	40.5
Pig	395	40
Horse	38	39

• Respiratory and cardivascular system

• Pulse

Pulse can be taken, in cattle at the coccygeal artery (at the tail head), in horses at the facial artery, and in goats and sheep at the femoral artery. Often cows will show a jugular pulse (neck pulse) which can be seen on quiet observation from a distance. Examination of mucous membranes, for assessment of peripheral circulation, can be done with the digestive system examination.

• Respiration

A healthy animal breathes quietly, alternating between chest and abdominal movements. Hard, gasping and short breaths are signs of sick animal. Nasal discharges and mouth breathing/panting are not normal except in stressful situations

Respiration examination, to determine or measure respiration frequency and type of an animal. The frequency is measured by calculating respiration cycle i.e. inspiration and expiration processes in one period of time, usually one minute

Normal respiration rates

Animal	Respiration (breaths/min)	Heart rate (pulse)
Cattle	10-30	60-80
Calves	30-60	100-120
Horse	10-14	30-40
Goat and sheep	20-30	70-90

If it remains difficult to measure respiration frequency visually, use hand by placing it near the nostril. The breaths will be sensed as result of expiration process, count them within one period of time. Respiration type can be checked by examining inflation and deflation of the thoracic and abdominal walls. The nasal mucosa can be examined with the mouth as part of the digestive system.

• Nose: A bit moist and tend to be wet in the outer part, no lesions, dirt, discharges or blockages. Look for vesicles. Pinch the nose, if liquid comes out meaning inflammation happening inside the nose. It can be clear, white, green, red, black or yellow liquid. A non-clear discharge is not normal.

• Visual: examination of the eye

Clean, clear and bright eye ball. Some dirt in the corners of the eyes is still normal. Conjunctiva are pink in color and no lesions found. Abnormalities that mostly found in the eyes are too much dirt covering the eyes, swollen eyelid, reddish (inflamed), yellowish (icterus) or pale (without colour). Examine the conjunctival mucous membrane (video) Discharges, blepharospasm

• Restrain animal's head properly
• Turn upper eyelid out, observe and note colour
• Repeat for lower eyelid

• Digestive system

• Mouth: Outer lips are clean, smooth and a bit moist. Lips will close properly. Mucous membranes of the oral cavity are evenly pink where there is no pigment, no lesions. Sufficient amount of saliva moistens the oral cavity. The tongue has evenly pink color, where there is no pigment, no lesions and can move freely. Scab in the lips, excess salivation or mucous membrane changes its colour (dark red/purple , yellowish or pale) indicate a sick animal. Tongue does not stick out.

• Mouth examination
  • Opening the mouth and look for lesions/erosions in lips, gums or tongue.
  • Tool and material used: Mouth gag/oral speculum/piece of wood
  • Restrain animal"s head properly
  • Open its lips/mouth till the gingiva is well-seen
  • If necessary, put on mouth gag or oral speculum (a stout branch or piece of wood)
  • Pay attention to lesion occurrences in lip mucosal, gingiva or tongue
  • Look closely at teeth. Observe any deformities
  • Smell the breath - foul smells may indicate mouth lesions or digestive disturbance. Get an idea of what normal ruminant breath smells like.

Determining animal age aims at revealing age based on tooth composition and erosion/wear. Tool and material used: Mouth gag/oral speculum/piece of wood

Results: The following are cattle age estimation based on tooth examination. Accurate aging is not necessary for clinical examination.

1. Under two years (permanent incisors are not found yet)

2. Two years (2 permanent incisors)

3. Three years (6 permanent incisors)

4. Four years (8 permanent incisors)

Mucous membrane examination; to determine cardiovascular quality. Mucous membranes may be examined in some places as in oral, conjunctive or vulva mucous membranes. You can now check peripheral circulation by pressing your finger against the gum and then quickly releasing pressure - this will force blood from the capillaries and it will turn pale. Colour should return within two seconds after releasing pressure.

• Abdomen: Check for abdominal distension. Bloat may occur if ruminants are subjected to sudden changes in diet. It will be seen as an obvious swelling in the upper left abdomen.

• Excretion: Animal defecates and urinates easily showing no signs of pain. Faecal consistency is normal.

• Genito-urinary system: check external genitalia including penis, prepuce in males and vulva/vagina in females. Check for abnormal colour and/or discharge. In females, check udder and teats, is she feeding young? Check milk appearance - blood or pus indicates mastitis.

• Mucous membrane - Examining vulva mucous membrane (video: Physical examination) Gait

A healthy animal walks with an even gait and places feet evenly without stumbling or knuckling over. It can walk backwards and can recover from sideways pushing. The stride is even and changes of pace are managed without difficulty. Legs can be lifted by hand and flexed in trained animals. Head remains steady when moving. Limping, lackluster or cannot walk are signs of sick or injured animal.

• Lymph Node

Some superficial lymph nodes can easily be observed/palpated below the ears, and at axilla and inguinal region. Touch the skin and find the bumpy shapes. They are not clearly seen or felt in normal condition. When inflammation occurs, swelling and pain may be evident in the areas where the lymph nodes are located.

Clinical examination checklist

Part of examination	Focus of examination	Finding
Behaviour/general	Appetite
	gait
	Body temperature
	Breath frequency
	Pulsus frequency
Head part
Eye	Colour
	Mucous
	Discharge
	Other thing
Nose	Discharge
	Odor
	Muzzle
	Other
Mouth	Colour of mucous
	teeth(condition and permanent teeth)
	tongue (color, wound, etc)
	Odor
	Discharge
	Other
Ear	Shape
	Odor
	Other
Lymph node	Mandibular
Neck Part
Fore limb	Swelling
	Wound
	Other thing
Breast part
General	Skin
	Feather / fur
Lymph node	Prefemoralis
Abdomen
Rumen	movement
	Other
Umbilicus (newborn)
Hind limb	swelling
Anus/ Vulva	Diarrhea
	Mucus
	Other

All observations should be recorded. Once the clinical examination is completed the investigator should consider the signs of disease shown and interpret them with the history to decide which diseases may be causing the problem (differential diagnosis list).

Where affected animals have died, a post mortem examination may be performed to look for changes that may provide diagnostic information. Where zoonotic disease is suspected, it may not be advisable to do a post mortem, which could spread infectious material widely. In particular, sudden death and outbreaks of sudden death in ruminants should not be subject to post mortem. Anthrax should be high on the differential diagnostic list in such cases.

Environmental examination

Background

Information about environment condition is important to obtain comprehensive information while conducting disease investigation. The importance of the environment is illustrated in the epidemiological triangle above, and should not be ignored. Some environmental conditions can affect the health such as poisoning which may be caused by environmental contamination from chemical waste. For instance, during the planting season where many farmers use chemical fertilizer that can contaminate grass, water and other livestock"s feed. Using the five senses can be used as a simple method of examination. For example, in a commercial chicken farm, strong smell of ammonia can indicate the poor level of cage hygiene and so on. Production systems, husbandry and presence of other species can be important. Examination of the environment is also addressed in the Field Epidemiology course

Learning objective

• Participants can explain benefits of environmental examination to get objective information.

• Participants can examine environment during disease investigation.

Content

Why environmental examination is important

• Environmental factors can influence as disease outcomes
• To identify the environmental factors that predispose towards the increased incidence of disease (class exercise)

What do we need to check?

• Housing and stocking density, fodder and drink container; the cage floor; size of cage; any dangerous materials in the cage; the smell of the cage, what else?
• pasture area; types of plants, structure of the area, the type of animal, presence of chemical contamination, presence of animal carcasses, presence of sick animal, what else?
• Presence/absence of insects or other vectors
• food sources: kind of food, the smell, colour, the presence of chemical contamination; fungi contamination; what else?
• drinking water sources; around the water sources, color, smell, the presence of chemical and biological contamination; what else?
• disposal of waste and trash location
• other species
• toxic plants
• access to water, recent flooding

What methods are used?

• Using five senses(with care);
  • Smell; odours around the cattle such as; strong smell of ammonia, foul odored, chemically-distinct odor, etc.
  • examine the food and drinking water
  • Sight; look the environmental conditions carefully, changes in color, shapes, etc.
  • Touch; feel the texture of the food, soil, etc
  • Hearing; listening to the noises that can cause stress

Selecting, taking and submitting relevant samples

Background

Laboratory testing may be required to confirm or assist in diagnosis. Before taking samples, the field officer should understand selection, collection and handling, and consider the investigation findings to avoid unnecessary samples. Samples are not merely from the livestock but also can be from the animal"s environment such as water, feed and soil. Advice on collection and submission of samples should be provided by the laboratory.

Learning objective

• Participants appreciate the benefits of diagnostic tests as part of a disease investigation

• Participants know when and how to collect samples for common laboratory tests

• Participants are able to explain proper ways to handle and submit samples for lab examination.

Content

After completion of history taking and physical examination, an investigator should be able to make a list of possible reasons for the clinical signs that an animal shows. It may be possible to reduce the size of this list by submitting relevant sample for laboratory examination. For example, a cow with a fever and noticeably dark urine may have anaplasmosis, or a kidney infection, or the urine colour may be unrelated to the fever. It will help to get a urine sample for laboratory examination. A blood sample may be of help in diagnosis of a blood parasite or other infection.

Sample types:

• Organ samples/intact tissue if a post mortem is carried out. Note: if sudden death do not do a post mortem
• Blood samples
• Fluids samples, swabs (pus, abscess discharge, etc.)
• Dead animal samples (carcass)
• Environmental samples (water, soil and other materials)
• Fodder samples
• Ectoparasites samples and endoparasites if post mortem carried out

Selected based on the direction of veterinarian.

Equipment required:

• Knife, scissors, forceps, scalpel, gloves
• Needles (different sizes for different purposes)
• Syringes
• Microscope slides
• Vacutainers - blood (red lid) for sera, ETDA (purple lid) for whole blood/plasma
• Cotton, tissue, alcohol,
• Sample media and transport devices

Sampling Method:

• Taking whole blood and blood smear
• Taking swab sample
• Taking feces sample
• Taking sample of residual feed, water
• Taking sample of skin scrapings
• Taking sample of rumen contents and vomit

Sample taking should be adjusted with the required information and conducted under vet supervision.

Submission, freight and handling

Officers should liaise with their laboratory for requirements and supply of material for taking samples and for approved methods of sample submission. Often there will be local practices that must be observed - for example, it may not make sense to take or send bacterial samples on a Friday, as they are likely to arrive at the weekend, and will not be useful by the beginning of the next week if the laboratory does not have standby staff.

Before you leave

Background

Disease investigation must be accompanied by provision of advice to owners and village authorities as appropriate. If necessary, treatment should be provided and any biosecurity requirements can be applied. The investigator must report the findings of the investigation in accordance with district reporting practice. iSIKHNAS has a facility for doing this by SMS messaging. If available it should be used, as this will link the case to the investigation and any follow-up or laboratory submission that has taken place. It will also include this information in reports as requested at dinas, province and national level. Consideration must be given to biosecurity and thoughtful cleansing/disposal of equipment as required.

Learning objective

• Participants are able to discuss actions to take before leaving investigation site.
• The use of iSIKHNAS and other systems of reporting is clearly understood

Content

An investigator should allow time at the conclusion of history taking and clinical examination to collate information obtained so that it adequately leads to the formation of an initial differential diagnosis - a prioritized list of possibilities that could account for the information acquired and the clinical signs that the animal is showing. Report the case in accordance with practice in the district.

• Recording and consulting with vet in case you find any specific abnormal clinical signs.

• Synthesis of information in order to make an assessment of the situation i.e. steps towards making a differential diagnosis. What are the most important clinical signs? What parts of the body appear to be affected? What is the nature of disease progression - acute or chronic? Are there other animals affected?

• Provide a useful clinical service. Within the bounds of your ability and authority, and in accordance with the directions of your supervising veterinarian, do your best to provide advice and treatment.Refer to supervisors as necessary.

• Think about biosecurity. Immediate reporting of findings is mandatory if a priority disease is suspected. If an infectious disease is possible, provide some advice about biosecurity. Review the section on biosecurity and biosafety above. Think about contagious disease. Are there any biosecurity practices that might be applicable in the situation. Refer to a supervisor if you are unsure. Biosecurity issues should be considered where you see many animals affected, serious clinical signs or evidence that the disease is spreading quickly. The equipment you used (including PPE if used) in the visit must be disposed of thoughtfully, with consideration to biosafety and biosecurity, and environmental concerns as applicable. Biosafety and biosecurity are addressed in the relevant sections of this handbook.

• Think about public health. If you think a zoonotic disease is possible, give some advice about the risks and how to avoid them.The zoonotic diseases covered in this project are the priority diseases, rabies, brucellosis, avian influenza and anthrax. Immediate reporting of findings is mandatory if a priority disease is suspected.

• Record your findings by using SMS reporting with iSIKHNAS (or by other means) which can be done on-site saving you time later. The case can be reported and linked to the original alert using the case ID from the pelsa report. iSIKHNAS will require you to identify the type of report along with the findings of the investigation, treatments, sample submissions, or to add comments. The list of SMS codes are available here. Reporting before you leave, will ensure you don't forget, and will allow you to find further information while you are there if necessary.

• Leave your contact details for contact by the owner or the community and ask information if there is changed disease incidence. Encourage them to work with the local pelsa.

• Schedule another visit to the case location if necessary.

Follow-up actions

Background

Responsibilities of the disease investigator do not stop on departure from the site. Even if the case itself does not require follow up, contact should be maintained with the pelsa who reported the case. Any samples taken must be packaged and sent to the laboratory in accordance with the requirements/instructions of the testing laboratory, and any samples for examination by the investigator should be managed appropriately. The information noted from the history and clinical examination should be managed to restrict the differential diagnosis and confirm that any treatment provided has been appropriate. There may be a requirement for further investigation in the case of spreading, wide ranging or novel disease or there may be an indication that control measures are necessary.

Learning objectives

• Participants are able to compile information obtained systematically for further analysis if required
• Participants recall management and submission of samples.
• Participants understand that good contact with reporting pelsa and livestock owner will encourage continued reporting.

Content

Field Information frequently is not well arranged. Findings from physical or environmental examination need to be reconfirmed with additional history, and vice versa. Disorganised information may result in poor conclusions. Skills to manage information systematically are required to help the veterinarian. Refer to the check sheet from the clinical examination section.

Develop a systematic table to make it easier in arranging all information.

Put findings into the right column in the table below. After grouping all findings into the appropriate column, analyze to find out connection among findings. Is there connection between the findings of history taking and physical examination? Mark those assumed to have connection, using colors or signs that can be easily understood.

Findings of history taking	Findings of physical examination	Findings of environmental examination
In accordance with history: RPS, RPD, RPK, RSL	In accordance with the examination table based on the region	Write down all findings
Write down the findings from the three lists that are likely to be related.

Examples of information analysis

Findings of history taking	Findings of physical examination	Findings of environmental examination
* Cattle cannot stand	Relatively fast respiration	No cattle was in the pasture for grazing
* It has been sick since the morning, all of a sudden	* Negative/no appetite	The water comes from the irrigation channel
* It does not want to eat and drink	* It does not want to walk as it can't stand	* The water is a bit murky
* Its mouth is bit foamy	* Body temperature is 39.50°C	* Fertilizer bag found next to the channel
Never been sick with these signs But, neighbour's livestock once had this and died	* Wounds in mouth
* The cattle is grazing in a communal pasture	* Enlarged lymph node in submandibular
No other livestock got sick with these signs	Normal eyes
Only about 5 families that release their livestock for grazing	Dry nose
The grass is relatively fertile	No foamy marks in mouth
* It is now planting season in that area	* Wounds found at the right back leg
* Paddy planted next to the rice field was given fertilizer yesterday

NOTE: Findings marked with dots are interconnected. For instance, it does not want to eat as it has wounds in its mouth and enlarged lymph node; it cannot stand as it has wounds in its right back leg. The planting season may link with the fertilizer and lead to possibility of poisoning.

Example notes. History, clinical and environmental examination

History	Clinical examination	Environmental examination
Mature cow	Pulse and respiration normal	No other cattle ill
Poor body condition	Mucous membranes congested (dark red), refill >2 secs	Enough grass
Not eating well	Temp 38.5	Other cattle in reasonable condition
Altered voice	Grunts when rising from ground	No fences, but untidy workshop in grazing area
Another cow died last year	Reluctant to move	Water looks OK
Has not had a calf for 2 years	Sensitive to pushing on ribs	No extra feed
Does not like to walk out in morning	? swollen abdomen	Fertilizer bag next to channel
The cattle are grazing in a communal pasture
No other livestock got sick with these signs
It is now planting season in that area
Paddy planted next to the rice field was given fertilizer last week

Example: The most likely relationships.

Write down the findings of the 3 parts that are likely related.

History	Clinical examination	Environmental examination
Foal 6 months	Rough coat	Enough grass
Other horses, including foals in area	? weak	Other mature horses in reasonable condition
Diarrhea	Coughs occasionally, looks at flank	No fences, but untidy workshop in grazing area
Tries to vomit	Temp 38	Water looks OK
Sometimes seen in other foals	Mucous membranes pale	No extra feed
One foal died last week, looked same	Pulse and respiration normal	Fertilizer bag next to channel
Poor body condition	? swollen abdomen
It is now planting season in that area
Paddy planted next to the rice field was given fertilizer last week

Reporting to iSIKHNAS

On completion of the investigation, a report is made for the supervisor, vet, or to the information system. The report, will allow all components in the system of animal health services to plan management, control and prevention strategy. The integrated animal health information system, iSIKHNAS, has been developed as an SMS and Web based information system. Through iSIKHNAS, it is expected that the officer can easily, quickly and practically do the reporting as well as to see the case progress through the Web.

• Immediate reporting of findings is mandatory if a priority disease is suspected.

• Follow up with case outcome (maintain contact)

• Follow up on laboratory test results

• Consider other possible actions:

• • Population-based investigation (see Field epi. Course)

• • Surveillance (see Surveillance course)

• • Population disease management (for specific diseases)

Points to note for investigating officers

Promote advocacy through musrembang activities, to provide "bottom up" advice to Dinas/BAPPEDA. Promote disease outbreak and control program management and control. In the long term these activities will require adequate planning to obtain funding (see Budget and Planning and Budget Advocacy courses in the iSIKHNAS wiki).