NILAI DIAGNOSTIK KOMBINASI GEJALA DEMAM DAN GEJALA/TANDA KLINIK LAIN DI DAERAH ENDEMIK MALARIA DENGAN KEJADIAN LUAR BIASA DI KECAMATAN PURWONEGORO DAN BANJARNEGARA, KABUPATEN BANJARNEGARA

Abstract

Background Malaria is still endemic in Central Java. Since 1998, malaria outbreaks have been reported in some regencies such as Banjamegara. Early diagnosis and prompt treatment is a cornerstone of malaria management especially during the outbreaks. Therefore, clinical diagnosis is important to detect malaria cases before confirmed by microscopic examination. Developing an easy clinical criterion based on symptoms and signs would be a useful tool in confirming the clinical diagnosis of malaria in rural areas. Objectives To select some clinical symptoms and signs that have high diagnostic values for malaria and to test which the combined symptoms and signs show the best performance in the clinical diagnosis of malaria. Method A cross-sectional method was used in this study. The field studies were done during the malaria outbreaks in the villages of Banjamegara and Purwonegoro Subdistricts, Banjamegara Regency, in February, 2002. Active case detection (ACD) was conducted to recruit all suspected malaria patients in the villages. All data were collected based on the structured questionnaires and then the blood slides were taken. Data was analyzed using descriptive statistics, a bivariate, and multiple logistic regression analysis (SPSS Program for MS Windows Release 11.0) were done thereafter. Sensitivity, specificity, positive and negative predictive values were calculated using 2 x 2 tables. Receiver Operating Characteristic (ROC) curve was developed to select the various cut-off points of the combined symptoms and signs. Results One hundred and five respondents were recruited and 61 (58.1%) of them were confirmed malaria cases (slides positive for P. faleiparum or P.vivax). Mean age ± 40 years (range 35-44 years). The significant symptoms and signs which can be used for clinical diagnosis of malaria were as follows : pale, cough, chill, sweating, cool feeling, and running nose. Based on all significant symptoms and signs, except cough and running nose, we proposed 11 significant combinations of symptoms and signs. In the ROC curve, the combination of pale, chill, and cool feeling is the best combined clinical symptoms and signs for confirming the clinical diagnosis of malaria. Conclusion The combined symptoms and signs consisting of pale, chill, and cool feeling has specificity of 93.5% and positive predictive value of 87.5%. This combination can be used to confirm malaria clinical diagnosis in a person with fever or history of fever in recent 72 hours during the malaria outbreaks in Banjamegara Regency. Latar Belakang Malaria masih endemik di Jawa Tengah. Sejak tahun 1998, dilaporkan Kejadian Luar Biasa malaria di beberapa kabupaten, seperti Banjamegara. Diagnosis dan terapi dini merupakan batu penjuru dalam pengelolaan malaria, terutama pada Kejadian Luar Biasa. Oleh karena itu, diagnosis klinik penting untuk deteksi kasus malaria sebelum dikonfirmasi dengan pemeriksaan mikroskopik. Pengembangan suatu kriteria klinik yang mudah berdasarkan gejala dan tanda klinik akan menjadi alat yang berguna untuk diagnosis klinik malaria di daerah pedesaan. Obyektif Untuk memilih beberapa gejala dan tanda klinik dengan nilai diagnostik malaria yang tinggi dan menguji kombinasi gejala dan tanda klinik terbaik. Metoda Metoda yang digunakan dalam penelitian ini adalah cross sectional. Studi lapangan dikerjakan saat Kejadian Luar Biasa malaria, Pebruari 2002 di desa-desa Kecamatan Banjamegara dan Purwonegoro, Kabupaten Banjamegara. Penemuan kasus secara aktif dilakukan pada semua penderita dengan dugaan malaria. Semua data dikumpulkan berdasarkan kuesioner yang terstruktur, dan sediaan darah diambil, kemudian dengan statistik dianalisis secara deskriptif, bivariate, dan regresi logistik multipel (Program SPSS for MS Windows Release 11.0). Sensitifitas, spesifisitas, nilai prediksi positif dan negatif dihitung dengan menggunakan tabel 2 x 2. Kurva Receiver Operating Characteristic (ROC) dibuat untuk mendapatkan kombinasi gejala dan tanda klinik pada berbagai titik potong. Hasil 105 responden diikutsertakan dan 61 (58.1%) temyata malaria (sediaan darah positif untuk 1'. falciparum atau P. vivax). Rerata umur penderita ± 40 th (rentang: 35-44 th). Gejala/tanda klinik bermakna yang dapat digunakan untuk diagnosis klinik malaria adalah: batuk, pucat, menggigil, keringat banyak, rasa dingin, dan pilek. Berdasarkan semua gejala dan tanda klinik bermakna tersebut( kecuali batuk dan pilek), didapatkan 11 kombinasi gejala dan tanda klinik bermakna. Pada kurva ROC, kombinasi gejala dan tanda klinik : pucat, menggigil, dan rasa dingin merupakan kombinasi gejala dan tanda klinik terbaik untuk menegakkan diagnosis klinik malaria. Kesimpulan Kombinasi gejala dan tanda klinik : pucat, menggigil, dan rasa dingin memiliki spesifisitas 93,5% dan nilai prediksi positif 87,5%. Kombinasi ini dapat digunakan untuk menegakkan diagnosis klinik malaria pada seorang dengan demam / riwayat demam dalam 72 jam terakhir saat Kejadian Luar Biasa malaria di Kabupaten Banjamegara.