END OF POSTING (8/12/11)

Day 13

Water Treatment and Water supply in Kuala Muda District

We were welcomed by Mr. Zaini and Mr. Kamaruddin this morning in an 'Meeting Room' like place were we begun our topic of the day without further ado.

Water supply and water treatment in Kuala Muda district is managed by 2 units; namely Pejabat Kesihatan Daerah(PKD) and BAKAS(Bekalan Air & Kebersihan Alam Sekitar). While the focus of PKD lies mainly in the urban area, BAKAS manages the water supply and sullage disposals in the rural area.

There are seven water plants supplying water for Kuala Muda District and they are located at:

1. Pinah Tuggal
2. Sungai Petani
3. Kulim High Tech
4. Tupah
5. Merbok
6. Gurun
7. Jeniang
8. Bukit Selambau

I seriously don't know how I ended up listing 8 places but there should only be 7 plants. Each of these plants are then divided to 4 course to be supplied to respective areas.

Water treatment steps:

• Water from source is first passed through aeration to be rid of odor.

• The water is then passed through a flocculation tank, that was much describe like a maze. At this stage aluminium is introduced into the water. The mud in the water forms sediment at the bottom by the action of the aluminium. Was attains clear colour.(reduced turbidity)

• Towards the end of the flocculation tank, water speed reduces allowing sedimentation.

• The water is then passed through filter tank that is made of sand. This allows for further mud clearance from water.

• the waster is then passed to clear tank where chlorine(kill microbes), fluoride(for good teeth) and calcium carbonate(to increase pH) is added

• Then the water is passed to another tank where the water sits for a minimum of 45 minutes to allow residue free water

• Lastly the water is sent to a reservoir and supplied to consumers

The maintenance of the treatment plant is carried out as and when required depending on the dirt burden. The plant needs more frequent cleaning on a rainy whether as compared to dry whether. For an eg : The filter tank is cleaned every 70hrs on the average.

This finally available water is nevertheless not readily drinkable. Consumers are thus advised to boil the water before consumption. Further more the path of the water from the plant to the consumer may be the cause of impurities in the water.(i.e. pipe may be broken and also store residual mud from water supply). The pipes are galvanized iron that does not rust. But there can be corrosive action by the chlorine in the water.

National Drinking Water Surveillance

Quality of drinking water are under constant surveillance based on specifications and guidelines by WHO. The parameters looked for are:

1. microorganism(weekly)
2. physical

• pH
• turbidity
• temperature

3. chemical(monthly)

4. pesticides(quarterly)

5. heavy metals (monthly)

Water Sample Collection For Surveillance

A water collection point is prefixed by SADA for collection of water sample for surveillance. Water of inspection of surveillance is collected only from this collection point.

1. the tap is turned on and water is allowed to run for 1-2 minutes
2. the physical readings are taken
3. then the tap is turned off
4. the tap outlet is burnt/heated up to kill microbes from the environment
5. then 100ml of water is taken for microbial sampling
6. the water collection bag contains sodium disulphate that neutralizes the chlorine
7. the sample is sent for investigation within 24hrs for microbial study

The samples are sent to Jabatan Kimia(Chemical Department) in Penang and Alor Setar

Water collection point

Burning of the tap and taking physical readings

Bag to place water sample

BAKAS(Bekalan Air & Kebersihan Alam Sekitar)

The focus of BAKAS is mainly rural area. Their Objectives are to increase the health status of the people in rural areas and to promote good environmental health. They also target to reduce the incidence of communicable disease.

Activities carried out:

1. provide clean toilet facilities(tandas curah)
2. to provide clean water supply/well
3. gravity fit(not in Kuala Muda)
4. build JKR pipe
5. Health Education

Allocation for 2011 permitted 100% financial coverage to build pipes for 46houses.

Tandas curah and the outflow pipe to the kok ring.

WASTE DISPOSALS

1. kok ring
2. sullage disposal kok ring

A hole is dug to accommodate the kok ring. Garbage is thrown in it and burnt once full.

This is sullage disposal kok ring. Waste of kitchen sink is collected in here.

-vachalla-

Day 12- Vector Control Unit

Today we began our day with briefing by the vector control unit, which is headed by Mr William. The briefing that was given to us was divided into 4 parts.

The 1st part : Case investigation, which was given by Encik Omar, one of the officers in the unit.

The 2nd part : Online registration of a case which was done by Mr. Burke

The 3rd part : Law & Acts of the government regarding the vector control cases (Dengue being the main), which was given by Mr. William

Lastly : Briefing on fogging given by Encik Pewira.

1. Case Investigation :

When a new case of dengue appears in district, the vector control department comes to know about it through phone calls, fax, e-notifications or by post. Informing the vector control unit is done by the general practitioners, hospital doctors, private hospitals and clinics. All of which have to inform the vector control unit within 24hours of the diagnosis.

If failed to do so, the specific clinic or hospital may be fined under the Act of Prevention & Control of Transmissible Disease 1988.

The order for case investigations :
1. New case reported by phone, e- notification, fax, or by post (more often than not by calls) by the hospital, GP or private clinics.

2. Health officer from the vector control unit goes to the specific hospital to investigate the case. Questions are asked regarding the disease.

3. Once information has been obtained in the hospital, the officer goes to the respective residence in search for any dengue mosquito breeding areas.

4. The officer then comes back to the office and the form is now re inspected, corrections are made, the form is completed and then passed over to the health inspector, Mr. William who then takes it up to Dr. Umi to be verified.

Note : In the form, each case of Dengue MUST have fever (the most important symptom) and 2 other associated symptoms.

Also, in the form, there is a section where the whereabouts of the patient 14days before the onset of the fever must be filled up. This is because the dengue incubation period is 14days and by obtaining this information, we would be able to trace back the source of infection.

Reason for investigation :

1. To know the status of the case - To find out if the patient hereby meets the criteria to be classified as a dengue case.

2. To know the cause of the infection - To know where the patient was when he got the infection.

3. To know the status of the spread of the infection - If there are 2 or more causes in the same area, it is known as a outbreak.

4. To take the most appropriate action to control the spread of dengue.

Aim of investigation :

Remove the virus from the area. - This is done by killing the adult and eggs

2. Online registration of a case.

When a new case appears, it has to be registered online. This is done by the District Health Centre to ensure they have all the information regarding the specific case in their system. The system was previously known as Veckpro but now has been changed to e dengue.

How it works?

When there is a new case in the district, it will be present in the e- notification. From here the vector control officer will log into the system, traces down the cases under vector control unit, for example dengue, and transfer it to e dengue. The complete details regarding the specific case is filled and appropriate actions are taken. The form is filled by the U29 officer and then transferred to the U32 officer and finally will be sent to the Health District Officer. Only then the case is considered complete.

3.Law & Acts by the Government.

What happens when a person is caught breeding larvae?
When a person is caught breeding larvae, a fine of Rm300 is charged upon him. Failing to pay the fine, he may be prosecuted.

To charge a person in court, permission to prosecute needs to be obtained, following which a fine, charge sheet and complaint are needed.

The 2 types of index that are used for dengue cases are the Aedes Index and the Breteau Index. The Aedes Index - Out of 100 houses, if one house has breeding, the index will read as 1%.

The Breateau Index - Based on the amount of larvae that is collected in containers. More than 5 containers per house labels it as dangerous.

4. Fogging.

Aim of fogging :

To kill mosquitoes that carry the virus.

There are 2 types of fogging that is usually done :

a) Thermal Fogging - the medication used for the fogging is heated at a high temperature of 1200 degrees Celsius with high pressure. At this temperature the particles are around the size of 5 - 50 microns. This allows it to float easily. Appropriate size is required because if the particle is too small, it may not work effectively and if it is too big, the particles will not be able to travel far enough to kill the mosquitoes.

b) Ultra low volume.

The concept of the fogging is to allow the gas to be in the air for a certain amount of time to ensure that the poison works on the mosquitoes properly.

Priorities for fogging are given to the areas with cases reported. Best time to do fogging is usually early in the morning at 8.30 and in the evenings around 5.30-8 pm (this is usually the peak time where mosquitoes are found to be more active). It also depends on the weather, rainy days fogging cannot be done. Officers who are handling the fogging must be dressed appropriately with the gloves, masks & proper shoes. The fogging medication should be sprayed in the house for 1-3 minutes for it to work adequately. Fogging is done from the back of the house heading towards the front and the fogging equipment is held at 45 degrees. Fogging is done for premises within of 200 meters radius from the reported case. Also during an outbreak, 4 rounds of fogging is done in the area with a minimum of 5 days and a maximum of 7 days between each fogging.

There have been no side effects of fogging upon humans that have been reported up to date.

Thank you.

Prepared by ,

-Nanthini-

Kuala Muda District Office - Day 11

KUALA MUDA DISTRICT HEALTH OFFICE- DAY 10

30/11/2011

We started the day at 9 am with a warm welcome by Mr.Yusof. The programme planned for the day was to learn the working system on how the outpatient clinic function in KK Bandar Sg. Petani.

The outpatient clinic was initially known as Klinik Pesakit Luar, but currently it is known as Unit Pesakit Luar. This unit consists of 8 medical officers and assisted by medical assistances and nurses.

There are 8 examination rooms and 1 treatment room. There are about 400-500 patients a day and more on Sundays. The operating hour for this unit is from 8am-5pm, extended hours 5.30pm-9.30pm. This unit covers mostly all the medical illnesses except for hypertension, diabetic and asthma which is covered by the non communicable disease clinic.

Patients that need medical attention will walk in to the clinic. Upon that they will have to register at counter 1 and will be given a number. Criteria for treatment charges are as below:
-Child below 1 year of age: Free
-School going children: Free
-Public: RM1
-Pregnant mothers for outpatient treatment: RM1
-Government servant/retiree: Free
-Disable/Special people: Free
-Speacialist treatment for each visit:RM5
-Non-Malaysian/migrant: RM15

After registration, another number will be given and patients will have to wait for their turn to consult/meet the medical officers. There is a separate counter for those who only want to do medical examination.

Together with the Unit Pesakit Luar, there is Pusat Rawatan 1 for TB patients. Here the medical officer will diagnose and start the multidrug therapy immediately.

--syastiny--

Kuala Muda District Health Office - Day 9

Non communicable Diseases Clinic(KK Bandar SP)

29 November 2011,Tuesday

WElCOME!

Well today our day started off a little bit later than usual, but nevertheless we were greated by Mr.Chong who is one of the four Penolong Pegawai Kesihatan Persekitaran PKD Kuala Muda who is pretty much in control of the NCD in KK Bandar Sungai Petani. He explained and enligthened us on various aspects of the Operations of NCD in Kuala Muda.

Basically the NCD's Discussed today was

1:Diabetes Mellitus

2:Hypertension

3:Asthma

4:Methadone Replacement Theraphy

Before we begin Mr Chong explained to us about why KK bandar SP has a separate clinic for NCD and not together with the existing outpatient clinic.

According to him, the initial plan was to make a dedicated clinic with a special unit which has its own MO and Nurses who are trained on multiple skills to bring about better control and organisation of the NCD in Kuala Kedah.

The congestion in the outpatient department will also reduce, and scheduling of appointments will be better with 2 separate clinics.

The vision of having a dedicated clinic for NCD is not yet fully achieved due to various reasons such as lack of staff, but hopefully in the near future this will be achieved.

In Kuala Muda Diabetes Mellitus is mainly controlled according to the CPG(clinical practice guidelines) for T2 DM and theres also a Quick Reference Guide for Management of T2DM which includes the screening criteria, values for diagnosis, management of T2DM, Recommended pharmacological therapy and also management of concomitant co-morbidities and complications.

Quick Reference for T2DM

In Kuala Muda the diabetic control target is 30% but only 11% is achieved, and the NCD unit is working hard in programs to bring the percentage up.

There is Quality Assurance program for DM by the NCD unit in Kuala Muda there is a continuous study done to record the current control and prevention programs and their effectiveness in reducing T2 DM cases in Kuala Muda.

The flow of patients with DM in the KK Bandar SP starts with the OPD. In the OPD the patients are screened and then directed to the NCD clinic to register as a DM patient. After this registration is done, the management of their diabetes begins.

After the registration and confirmation with OGTT about their condition the patients are then counselled about measures on controlling DM and lifestyle changes to be made in a diabetic patient.

Well this includes preparing healthy meals, exercising, insulin injection techniques, insulin induced hypoglycemia and diabetic foot care.

DM patients are managed by BIDS( bedtime insulin daytime sulfonamide)

As for Asthma and Hypertension the flow of patients is the same as in diabetes, but only the management defers.

As for Asthma patient is screened in the OPD , Emergency or are referred from hospitals to be managed at KKBSP.

Patients usually children are given education on how to use the inhalers and how to prevent from getting asthmatic attack by avoiding the triggers such as pollen, dust, cold weather, animal dander. Parents are also educated on what to be done during such attacks.

In cases of hypertension patients below 140/90 are already classified under prehypertensives and are provided with counselling as to how their BP can be brought down and prevented from shooting even higher.

Whereas in Patients with BP of more than 140/90 are started with treatment and given appointments accordingly to observe improvement and control.

Visit to the card room!

Next Mr. Chong brought us to the card room where all the records of the patients with DM, Hypertension and Asthma are kept. Here are some pictures:-

The cards are coded according to disease

Diabetes- Green

HPT- Blue

Asthma- Pink

Previously the card system started for the diabetic patients only, with a green card. In the early stages hypertension cards were not coded and were just recorded on hardcover notebooks. Now there is cards for all three diseases.

Further about how the card are used will be futher elaborated below, so read on....

Visit to S/N Eiedey Suraiana's Office!

Lets start with a little bit about S/N Eiedey Suraiana....

S/N Eiedey is in charge of registration of the patients, i learned that she is the only person who does patient registration in KKBSP and our group was really grateful that with a busy schedule she managed to explain to us a little about the registration process and statistics.

Here's a picture of her :)

According to her, 10 new cases register each day for diabetes and only after an OGTT and not solely based on a RBS.

An important part of the registration is the card issued. Every patient has 2 cards, one bigger card for hospital records which are kept in the card room and a smaller one which is carried by the patient, an updated each time the patient visits the clinic for appointment.

The cards are audited frequently to check if the CPG(clinical practice guidelines) are followed.

The smaller card is carried by the patient and bigger one kept in the card room of KKBSP

There is also a registry for the patients who default their appointment, this works if a patient does not show up for their appointment, after 2 weeks of no show name is included in the defaulters list.

On average 10-15 patients default their appointment each day. For the month of November, 128 patients defaulted their appointment. Out of which 82 patients contactable, 44 cannot be contacted, and 2 patients died.

Patients who were contacted were given a new date and counselling on the importance of their visit to the clinic.

Visit to the Methadone Clinic

The function of this clinic is to carry out the Methodone Replacement Theraphy for drug(opioid) abusers.

Here the patients are registered and are supposed to come everyday to get their daily dose of methadone which is 25mg/day.

This program is aimed at reducing spread of diseases which spread due to sharing of needles, such as HIV AIDS.

It was started at 2007, and it is run by one FMS, one MO, one AMO and one staff nurse. It is a cooperative program with Agensi Anti Dadah Kebangsaan(AADK).

Here we were briefed by Mr Khairul Hafiz futher on how it is carried out.

The picture above shows the criteria and the flow chart of how a patient is registered under the MRT program.

First HIV screening,Hep B screening, renal profile and LFT is done.

LFT serves as a factor to determine whether the patient would be able to tolerate methodone,not end up with further side effects due to inadequate Liver Function. So patients who do not pass the LFT will not be accepted into the MRT program.

Now the flow of patients from the methadone clinic works as follows....

1.Visit methadone clinic and attendance is taken and each patient is given his own mug ,which looks something like this :-

2. Then this glass is carried to the pharmacy where the pharmacist in charge will dilute the methadone and patient drinks it under observation.

Urine test is done everyday for 2 months for each patient. This is to ensure that the only take the methadone given by the clinic and not add on futher drugs. Patient with positive for other drugs 3 times, are no longer entertained and name striked off the registry.

The problem with this theraphy is mostly due to lack of patient cooperation this is because there are patients who use drugs added to the methadone given by the clinic and try to fake the test results by using other persons urine. A measure taken by the methadone clinic is to observe the urine test. A male MA is to observe the patient urinating and performing the test.

This ensures that the purpose of the test is served.

Today was one of the most beneficial days of our posting so far, Mr Chong who was very enthusiastic about teaching us really helped us understand better the NCD unit.

With that i would like to end my post for the day, if any typo error noted please forgive me :)

Cheers!!

-G.Suriaraja

Kuala Muda District Office - Day 8

Public Health Care -Day 8

We were received by Mister Chong, Senior MA around 9am in the Meeting Room of Kuala Muda District Health Office. Mr. Chong seemingly a peoples' person wanted us to introduce ourselves before we officially started the topic of the day. Starting from the group leader Vinod, we introduced our names and hometown; also a little about what's famous in each hometown.

He later screened two Power Point presentations regarding the Primary Health Care in Kuala Muda district.

Content of the presentation consists of the Vision and Mission of Malaysian Health Ministry’s approach to the Primary Health Care(PHC).

Definition Of PHC

Essential health care, Based on practical, scientifically sound and socially acceptable methods and technology. Made Universally accessible to individuals and families in the community by means acceptable to them.

It is the first level of contact of individuals, the family and the community with the national health system, bringing health care as close as possible to where people live and work and constitute the first element of a continuing health care process

The Malaysian Health Ministry looks forward to achieving healthy individual, family and society through health programme that is fair & just, affordable, efficient, with appropriate technology and one that caters for the need of the locals. This programme also gives importance to health promotion, health education, and the improvement of quality of life.

MISSION

To promote the involvement of the public in the health promotion and to enable the public to achieve optimal health status possible

To value health as an asset

To steps to further enhance and maintain health status

To enjoy a better quality of life

To achieve this, the ministry has come up with 8 Aims ;

Wellness Focus – devoted to provide health for life

Person Focus – focusing on one's service and ensure that the service is available on time and at placed required

Informed Person - provide accurate information and knowledge through health education campaigns that allow a person to make decision about health

Self Help - enhance the ability of individuals to handle their own health through knowledge care Provided at Home or Close to Home - using multimedia network in providing physical and virtual service in home or community

Coordinated, Continuous, Seamless Care - providing integrated health care services that cover a wide range of facilities and levels of life

Services Tailored to Individual or Group Need - special services to meet the needs of individuals or the groups in certain circumstances

Effective, Efficient and Affordable Service - quality health services that are accessible, integrated, simple and affordable

Basic 8 elements

Health education

Food supply and proper nutrition, safe water and basic sanitation

Maternal and child care, immunization

Family planning

Mental health

Prevention and control of endemic disease

Basic treatment of health problems

Provisions of essential drugs

Basic Health Services

Out-patient care service, including mental health and provision of essential drug

Food supply and proper nutrition

Safe water and basic sanitation (BAKAS)

Maternal and child care, including immunisation and family planning

Home delivery and nursing

Prevention and control of endemic diseases

Dental care

School health service

Additional Services With Expanded Scope

- Geriatric health care

- Adolescent health care

- Community mental health

- Occupational health

- Rehabilitative services

- Home care nursing

Research Findings:

40% need not be admitted

60% seen at OPD, are unnecessary visits

70% are preventable conditions

The Focus of PHC

Medicine vs Health

Centralised vs Distributed

Disparate vs Integrated

Inequitable vs Equitable

Your “NEW” Role

AS A MA

Health advocator

Counselor

Team Player

Call-Center Manager

Clinic Practitioner

AS A CLINICAL PRACTITIONER

Well Adult Clinic

Geriatric Clinic

Adolescent Clinic

Quit Smoking Clinic

HIV/AIDS Clinic

Special Clinics- Hypertension, Diabetes, Asthma

The Malaysian Hospital system is a 2 tiers system.

Where the main hospitals are centered around district health clinics. Patients are to go to district health clinic out patient department for their problems and if required are sent to hospitals for referral. (details available in day 2)

Mr. Chong had then taken us for a stroll around the district clinic mainly to the NCD(Non-Communicable Disease) outpatient. He then explained the management steps and statistics of these disease reported each year. He also told steps of case follow up and how the diagnosis are made before commencement of treatment. He showed us around the "card room" as how all the cases are recorded manually.

There are over 12,952 recorded cases of diabetic mellitus type 2 in this district clinic alone!! And there are 10 new cases recorded daily, on an average. Kedah holds the 2nd highest record for people with diabetic type 2 after Negeri Sembilan. The statistics has doubled from a 11% to 30% in over 5 years.

Ninth MP (Malaysian Plan)

Primary Goals

- Prevent and Reduce Disease Burden

- Enhance Health Care Delivery

Supporting Goals

- Optimisation of Resources

- Enhance Research

- Manage Crisis and Disasters

- Strengthen Health Information MS

Primary Care Services

1.Prevent and Reduce Disease Burden

- Treat the ill

- Manage those with risk

- Prevent the onset of preventable risks

2.Enhance Health Care Delivery

- Fast Access

- Safe and high quality

- Hassle-free and better comfort

3.Optimisation of Resources

- Multi-skilling

- Sharing

- Remote management

4.Enhance Research

- Participate towards evidence based planning and intervention

5.Manage Crisis and Disasters

- Increase HR capacity and capability

- Adequate and appropriate facilities

- Current’ protocols for management

6.Strengthen Health Information MS

- Reduce repetitive request

- Increase safety through reducing error

- Enhance sharing of data and info facilitate continuity of care.

7.Current challenges - PHC

- High load of patients to doctor

- (30m & 13m) = 40 -50 m (total encounters)

- (Medical assistants / Nurses)

- 1000 drs (130 FMS)

- 6300 nurses (3700 SN)

- 2000 MAs

- Increasing scope of services

- Lack of building space and equipment

- Poor maintenance

- Increasing demands by clients

The card room

The different cards as patient copy and staff copy

(small - patient)

Organisation chart of Kuala Muda district Hospital

Organisation chart for OPD

This image is that of four different types of survey form:

• Teenagers
  


• Adult female


• Adult male


• Senior citizens

These survey form are for screening purposes that target and attempts to get hold of specific problems faced by society of varying age groups. The surveys are done as and when required and collected back for assessment. If problems are detected through this survey form, the patient are called up for review and treatment.

-vachalla-

Kuala Muda District Office - Day 7

Assalamualaikum and Salam Sejahtera.

Review of day 7 (24-11-2011)

Today we visited the Food Safety and Quality Unit of Kuala Muda District Office. The day sets of at 9am in the morning with a brief welcome speech by En. Zainal, Head of Food Quality and Safety Unit. According to En. Zainal Food Quality and Safety Unit was once under Environmental Health Department but now it stands independently by itself. Currently the leader of the unit is En. Zainal and the organization chart of Food Quality and Safety unit of Kuala Muda district are as follows:-

Encik Zainal, Head of Food Quality and Safety Unit of

Kuala Muda District

Plans for Food Quality and Safety Unit starts at the Ministry level where the Ministry Department prepares the plan and passes it to the state while state passes the plan to the districts offices like Kuala Muda District Office. All the plans prepared by the ministry depends on the population of a particular district. However, according to En. Zainal some of the plans could not be executed since they lack officers at the district level. Currently there are only 6 officers working in Kuala Muda Food Quality and Safety Unit.

The following are the major and minor activities conducted by Kuala Muda Food Quality and Safety Unit:-

Major activity:-

1. Food sampling

• 900 samples in Kuala Muda were collected this year(2011)
• main form of samples include chemical, physical and biological samples
• samples are collected according to schedule
  
• samples are collected from restaurant, food company, schools(100% priority is given and done twice per year)

Minor activities:-

1. Pengeluaran sijil kesihatan (Health Certificates) for food product to be exported or imported
2. Inspection of restaurant premises

Types of sample:-

1. Physical - labeling, expiry date, identification code
2. Biological - DNA samples
3. Chemical - shops, restaurant, supermarkets, university

Sample collected, sealed and labelled

Procedures of chemical sample collection

• task conducted by minimum 2 officers incharge
• sometime doctors are also involved but only at state level
• for dangerous/high risk operations, a police officer will follow the team
• person incharge will be given a power card ('kad kuasa')
• preparation will be done according to check list in their office
• discussion of type of sample to be collected will be held
• the 2 officers will then depart to sample collection's site
• once there, the officers will introduce theirselves to the owner (must show the 'kad kuasa')
• explains to the owner of the shop regarding type of sample to be collected
• at least 1 member of the shop or restaurant has to follow the person incharge all the time as a witness, preferably the owner himself
• collected samples are divided into 3 portions, kept in 3 separate sample collection bags and labelled appropriately
• collected samples will be sealed
• 1 bag is sent to the lab for chemical analyzation, 1 bag is given to the owner and another is kept at the department for reference
• results take about 2-3 months, once results are out the findings are discussed
• if found guilty action will be taken against the owner
• if not, case is closed.

All penalties are based on the following acts:-

1. Akta makanan
2. Peraturan-peraturan makanan
3. Peraturan-peraturan pengurusan premises

In addition to that, all penalties also depends on the level of fault as well. Maximum penalty can reach up to RM100000 fine.

Location of food lab:-

1. Pulau Pinang (chemical samples)
2. Butterworth (microsamples)
3. Bukit Kayu Hitam

According to En. Zainal, Food Quality and Safety Unit officers are trying their level best to respond to all the complaints they receive (at least within 3 days). However, they give main priority to food poisoning whereby the officers will immediately respond (within 24 hours) and reach the location of complaint once they received such complaint.

Similarly, during sample collections, samples are collected in 3 different sample collection begs where each beg will be sealed and labelled. It is important to seal sample begs to prevent any unwanted fraud to occur. Unsealed sample begs will not be stored or analysed. Having said that, one of the beg will be sent to the lab for analyzing propose, another will be given to the owner whereas 3rd sample will be stored for future references.

All collected sample will be stored in their very own store room. Foods that can last in room temperature are stored in store racks while the others in refrigerator. Each sample can be stored up to 180 days beyond which it will be discarded.

Sampel collection beg

Food store in refrigerator

Some of the challenges sample collection officers usually face during their duty includes poor cooperation from owner, when owner is not around and threat from workers.

Thank you.

-Ravikhumar-

Kuala Muda District Office - Day 6

As for this day, on 23/11/11, we had our program in Klinik Kesihatan Bandar, Sungai Petani. We started the day at 9am, with a warm welcome by Mr.Yusof, the person in charge of us for the day. The program planned for the day was to learn the working system on how the outpatient clinic, x-ray department, pathological lab and pharmacy function in the Klinik Kesihatan Bandar Sungai Petani.

Firstly, Mr Yusof briefed us about the activities for the day. Briefing was held in the non communicable disease clinic’s counseling room. Mr Yusof explained to us about the non communicable disease clinic. The non communicable disease clinic covers patient with hypertension, diabetic and asthma. These patient doesn’t have to go through the outpatient clinic ( Unit Pesakit Luar). Patients have to make an appointment to meet the doctor in this clinic and not walk in. Patient that had registered with this clinic, will have their follow up here too. There are about 3 doctors in this clinic and each day there will be about 200-300 patients, more on a Sunday.

Despite that, in the clinic, there is a counseling room where health education and counseling will be given to the patients. Counseling usually done by the nurses, pharmacist and also the dietician (Pegawai zat makanan). The pharmacist will counsel the patient regarding the medication, doses and side effect of a medicine. The dietician do come occasionally and advise the patient about their food intake and importance of having a proper diet. Diabetic educator will educate the patient about diabetic, complication prevention and also diabetic care.

After that, we proceeded to the outpatient clinic. Initially it was known as Klinik Pesakit Luar, but now it is known as Unit Pesakit Luar. This unit consists of 8 medical officers, medical assistances and nurses. There are 8 examination rooms and 1 treatment room. There are about 400-500 patients per day on more on Sunday. The operating hour for this unit is 8am -5pm, extended hours 5.30pm to 9.30pm. This unit covers mostly all the medical illness except for hypertension, diabetic and asthma which is covered by the non communicable disease clinic.


Patients that need medical attention will walk in to the clinic. Upon that, they will have to register in counter 1 and number will be given. Criteria for treatment charges are as below:- Child below 1 year of age - free

- School going children - free
- Public - RM 1
- Pregnant mothers for outpatient treatment - RM 1
- Government servant/ retiree - free
- Disable or special people - free
- Specialist treatment for each visit - RM 5
- Non Malaysian/ migrant - RM 15

After registration, another number will be given and patients have to wait for their turn to meet the medical officers. They have a separate counter for those who want to do only medical examination. They will have to register and get their number to meet the medical officers. Charges for medical examination depend on the tests that are done.

We are then brought to the treatment room, where a medical officer, Dr Suresh briefed us about the common cases seen. The most common case seen is acute respiratory infection. Furthermore, if the medical officer suspects some severe disease, investigations will be ordered or patient will be referred to the hospital. Apart from diagnosing, the medical officers also will order investigations and write prescription slip for the patient. Medical certificate will not be given to patient after 5pm. Previously, when there is overcrowding of patient and lack of medical officers, the medical assistance are allow to examine the patient ( minor cases). Jabatan Kesihatan Negeri (JKN) has come out with a rule that 100% of the patient has to be seen by the medical officers and not the assistants. Flow chart of triaging outpatients are as below :

In the outpatient clinic, there is also procedure/ treatment room. This includes treating the emergency cases that comes to the clinic. Facilities and equipments available in the room are as follow : - emergency trolley - daily dressing - procedures ordered by medical officers such as suturing, blood withdrawal - nebulizer – foe AEBA patients - ECG – monitor the cardiac activity

As for emergency cases, treatment is given first, and then patient is asked to register.

Together with the unit pesakit luar, there is Pusat Rawatan 1, which is the TB room. Here the medical officer will diagnose and start the multidrug therapy immediately. Patients will present with symptoms of tibi in the outpatient clinic. When the medical officer suspects it, patient will be screened and if it’s positive, medication will be started. The TB room is actually a division of communicable disease control department (CDC). The head of the division is Dr. Umai which is placed in JKN ( Jabatan Kesihatan Negeri) . She is responsible of monitoring the program carried out by the department. Despite that, there is a team who goes home visit in case of default treatment. Patient can also get their medication from Klinik Desa.

X-Ray Department
Next, we were brought to the x-ray deparment. X-ray is one of the service of unit pesakit luar. We were briefed by an x-ray technician Pn Zainah. The organization chart of the department is as follow :

The head of the department is district health officer 1 and followed by district health officer 2. It is followed by x-ray technician. The department has 2 x-ray machine, and no CT/MRI facility. There are two type of x-ray machine, digital and conventional. Conventional type of machine is used in KK Bandar, Sungai Petani. After taking the x-ray, the film has to be process in dark room. It usually takes 5-10mins to process the film. For those whom are working in this department, they are exposed to radiation. To access the radiation level, a film card is given to each worker. The workers has to carry the card on them when they working. Every month, the card is sent for examination and the radiation let they will be doing office level is noted. If the radiation level of the technician is high, the technician wont be working in x-ray room, infact they will be given less job and office work.

If the patient is pregnant, they have to inform the x-ray technician as x-ray film won’t be taken. It is to prevent the radiation exposure on the baby.

Next, we went to pat hological lab. Briefing was done by Sister Cheah. In the pathological lab, simple test are done except for tissue culture and sensitivity.

Test available

· Urine analysis ( UFEME) · Urine micro albumin · Urine pregnancy test · Total serum bilirubin NNJ · Renal profile · Liver function test · Blood glucose · Plasma glucose · HbA1c · Fasting lipid profile · Serum uric acid · Serum calcium/ phosphate · Full biochemical screening · Full blood count · ESR · VDRL · Dengue test · Blood grouping · Rapid HIV test · Sputum AFB · Gram staining · BFMP · Wet smear for trichomonas · Stool FEME

This department consist of medical lab technician ( 3-5 of them) whom will be running all the test. Patient will come with the request form from the medical officers, and examination will be done. Some test’s result can be available immediately but some result will be available after few days. They have machines and analyzer machine to run the entire test.

Soon after that, we went to the pharmacy department. Briefing was done by Pn Natrah. The department is in charge of packaging and dispatching medication to the patients. The department includes per packing unit where the medication are prepared in various sizes,drug name,dosage,batch and expiry date. This pre packed drug later will be sent to the intergration and substor in the pharmacy department itself. The intergration stor is responsible for the drug supply/ medicine supply to the entire health clinic under Kuala Muda district. Nowadays the commonly used drug comes in a blister pack. Most common drug given to the patient are anti diabetic, anti hypertensive, paracetamol, cough mixture and antibiotics.

Patients whom want medication have to have a prescription slip issued by the doctor. With the slip, they can come and collect the medication. Patient with chronic diseases usually will be prescript for 3 month medication, but in the pharmacy they will give medicine enough for a month. After that, the patient has to come and collect medication again. Patients can inform the pharmacy earlier that they are coming and collecting the medicine via · Call & collect· My Sms· Email

If the patient is using any of these services, they will leave their prescription slip in the pharmacy and a card will be given to them. Date of the next medicine collection will be noted there.

The supply of medicine in the pharmacy stor is for a month. The wastage rate of the drug is low as 0.2%. if the supply is not enough, the drug can be taken from the intergration store which is situated in KK Bandar itself.

In a nutshell, we learned alot on how are the different working system of different departments in Klinik Kesihatan Bandar. Thanks to all those who gave us the briefing and explain each and everything.

-Karoshini-

Kuala Muda District Office- Day 5

As for this day, we had programs planned for us at Klinik Desa Sungai Layar and Klinik Desa Bujang. We went to Klinik Desa Sungai Layar first at 8a.m and we were welcomed by Matron Hasnah Wong. She was very helpful and gave us a very good idea on what exactly are the functions of a Klinik Desa.

Klinik Desa Sungai Layar is under Klinik Ibu dan Anak Kuala Muda. It is a new clinic which was completed in the year 2009 and started operating on August 2009. It is mainly run by one

Matron and her nurses. They also have one staff and one Jururawat Masyarakat on-call everyday. There is no doctor in the clinic on a daily basis but either a Medical-officer or House-officer comes once a week, which is on Tuesdays, for all the referred cases. Klinik Desa Sungai layar has the third highest workload.

The services offered by these clinics are:

1) antenatal and postnatal care

2) immunisation for children since birth up to 7 years old.

3) Family planning- only a few methods of family planning are offered in this clinic, such as Noriday, Rogevidon and Condoms.

Both of these clinics offer the same services and the admnistration and functions are all similar except that Klinik Desa Bujang comes under Klinik Kesihatan Merbok.

The antenatal and postnatal care offered are similar to the MCH Kuala Muda. Since these have been well explained and elaborated under the post by my fellow group mate Sheela on day 2, i'll just explain briefly. Antenatal visits mainly consist of height, weight and BMI measurement, blood test, Blood sugar profile, blood pressure, Physical examination (mainly measuring the symphyseal fundal height), and follow up. As for booking, most of them are expected to come for booking before 12weeks of gestation. It is important to do booking before 12 weeks of gestation to detect baseline blood pressure which is an essential part of pregnancy. Those who do not make it before 12 weeks must give a valid reason as to why they did not come early and this has to be reported by the nurses to the higher authority. The target is to achieve at least 85% of booking before 12 weeks of gestation. They also have a monthly target to be achieved, which includes both new and repeated cases. If this target is also not achieved, reasoning must be given. An important part of antenatal visit is detecting diabetes in pregnancy. There are almost more than 40% of mothers who come with Gestational Diabetes Mellitus to these clinics. These cases are labelled as high risk based on the appropriate color codes and serious cases will be referred to the hospitals. Mothers are also given Tetanus toxoid(ATT) during their antenatal visits. 2 doses for primi and 1 dose for those who have been pregnant before. ATT coverage in 100% in these clinics. For those who are detected to be anemic, low hemoglobin(Hb) they will be given Hematinics and a proper advise on how it has be taken along with an appropriate diet. They will be followed up and if still no changes, they will be referred to Klinik Kesihatan, and finally the hospital.

Besides just providing care for Malaysians, these clinics also take care of immigrants, including the illegals ones. Immigrants are charged RM15 for the services, but medications are free of charge. RM200 for home deliveries. Illegal immigrant cases must be reported to the immigration first before any action is taken.

Postnatal cases are seen both in the clinics and at homes (for high risk cases). Home visits are mainly for pregnancies with complications that require extra care and supervision. There will be one nurse who travels by her motorbike to the respective homes and keeps a check on these patients. They will be followed up until they have fully recovered from their problem. Sometimes, the number of homes visited may be more than the number of patients that were actually seen, this is because some of them may not be at home during the visit. So, when this is recorded, it will show higher number of homes than the number of patients attended.

Immunisation for new born babies till 7 years old are available. These will be given according to the immunisation schedule. There is a separate room for immunisation which is air-conditioned for the safety of the vaccines. This will be done by an experienced nurse and so far there has been no any problems or side effects reported.

Both the clinics consist of the main hall which is where the registration is done and the waiting room is. There is a room for the doctor, an examination room where pap smear and other examinations are done, an immunisation room, and a small lab where blood is drawn to check the hemoglobin level, glucose level and to carry out other simple investigations.

Attached below are some pictures taken during the posting here:

Organisational Chart of Klinik Desa Bujang

The Timetable for Klinik Desa Bujang

Map showing areas covered by Klinik Desa Bujang

In a nutshell, these clinics play a vital role in the care and safety of mother and child. We had a wonderful experience throughout our posting in these 2 clinics. Further more, with the cheerful Matron Hasnah Wong, our visit was indeed informative and educational.

- Sai Priyalatha Mariapan -