BUKU PINTAR PERNAFASAN

CHAPTER 1 PNEUMONIA (Watch the video through video bar link)


PENDAHULUAN

Latar Belakang
Pneumonia merupakan penyakit akut dimana ruang udara alveolar pada paru-paru mengalami peradangan dan menjadi terisi dengan cairan dan sel-sel darah putih,12 serta menimbulkan penampakan infiltrat putih pada foto polos dada.3 Hal ini dapat diakibatkan oleh bakteri, virus atau infeksi parasit juga dapat disebabkan oleh agen-agen noninfeksi seperti bahan kimia atau benda asing yang teraspirasi. Kasus pneumonia terparah disebabkan oleh bakteri terutama Streptococcus pneumoniae (pneumococcus) dan Haemophilus　influenzae.
Pada negara-negara berkembang dimana penderita seringkali ditangani tanpa bantuan dokter, WHO mendefinisikan secara sederhana pneumonia berdasarkan tanda-tanda klinis seperti episode batuk akut atau kesulitan pernafasan yang berasosiasi dengan peningkatan laju pernafasan.22 Selain itu meskipun Pneumonia dikenal sebagai penyakit yang dapat terjadi pada semua golongan umur, pneumonia merupakan penyebab utama kematian pada 1.9 juta anak dibawah usia 5 tahun di dunia,26 sehingga pada makalah ini pembahasan akan dibatasi pada pneumonia anak.
Sejarah memperlihatkan pneumonia sebagai penyebab utama kematian pada anak di negara-negara maju seperti Amerika Serikat pada era 1900, yang diperkirakan telah membunuh 47 dari 1000 anak dibawah usia 5 tahun pada masa itu.15 Perbaikan gizi dan standar hidup di negara-negara maju pada 40 tahun awal di abad 20 menghasilkan pengurangan yang substansial pada tingkat mortalitas akibat pneumonia sebelum antibiotik sebagai penanganan yang efektif tersedia. Akan tetapi di negara-negara berpendapatan rendah di Asia dan Afrika, pneumonia tetap menjadi penyebab utama kematian anak. Pada negara-negara berkembang, lebih dari seperempat anak memiliki episode klinis pneumonia setiap tahunnya selama 5 tahun pertama kehidupan mereka.16 Angka rata-rata menunjukan 2%–3% anak yang menderita pneumonia setiap tahunnya memiliki tanda-tanda klinis pneumonia yang parah dan memerlukan penanganan di rumah sakit dengan sebagian besar diantaranya dapat berakibat sangat fatal hingga menyebabkan kematian.16 Hal ini juga didukung dengan data yang menunjukan untuk 1000 anak yang dilahirkan, sekitar 100-150 eposide-episode pneumonia yang parah meningkat pada usia dibawah 5 tahun pertama, terutama dalam 2 tahun pertama kehidupan. Kurang lebih 21% dari kemaian pada anak disebabkan oleh pneumonia,26 dengan sebagian besar terjadi di negara-negara berkembang dengan tingkat mortalitas 60–100 per 1,000 anak dibawah usia 5 tahun;21 yang menunjukkan bahwa untuk 1000 anak yang lahir hidup 12–20 diantaranya mati karena pneumonia sebelum ulang tahun mereka yang kelima.

Tujuan dan Kegunaan
Sebagian besar pihak telah mengetahui mengenai tingginya jumlah kematian anak akibat pneumonia di negara-negara berkembang. Akan tetapi hanya sebagian kecil yang memberikan penjelasan mengenai pneumonia pada anak dan faktror-faktor yang mengarah pada kematian. Beberapa studi telah menunjukkan bahwa tingkat mortalitas pada penderita pneumonia berasosiasi dengan malnutrisi, sanitasi, higienitas, atau secara garis besar dengan kemiskinan serta kurangnya akses pada fasilitas kesehatan. Akan tetapi pembahasan terlalu jauh mengenai masalah akan meningkatkan kompleksitas masalah dan menyebabkan kengganan masyarakat untuk memahami masalah pneumonia ini.
Peningkatan pemahaman masyarakat mengenai masalah pneumonia ini, bersamaan dengan tersedianya informasi yang lebih terperinci mengenai etiologi dan patofisiologi penyakit, diharapkan akan dapat menghasilkan pendekatan-pendekatan baru untuk mengatasi tingginya masalah global kematian anak akibat pneumonia.


HASIL DAN PEMBAHASAN

Kejadian Pneumonia Pada Anak (Epidemiologi)
Rudan et al.17 telah menghitung dan mempublikasikan perkiraan global pertama kejadian pneumonia klinis pada anak berusia kurang dari 5 tahun pada tahun 2000. Perkiraan ini didasarkan analisis dari data 28 studi longitudinal komunitas terpilih di negara-negara berkembang diantara tahun 1969 dan 1999. Analisis memperlihatkan bahwa kejadian dari pneumonia klinis pada anak dibawa usia 5 tahun di negara-negara berkembang di seluruh dunia mendekati 0.29 juta episode per tahun-anak. Jumlah ini sama dengan 151.8 juta kasus baru setiap tahun, 13.1 juta atau 8.7% (7–13%) diantaranya cukup parah dan membutuhkan perawatan rumah sakit. 8 Lebih jauh lagi di dalam World Health Report 2000, WHO memperkirakan 4 juta kasus juga akan terjadi di negara-negara maju di seluruh dunia. (Tabel 1).11

Hal ini menarik perhatian sebagian besar para praktisi kesehatan masyarakat untuk menghitung penyebaran 156 juta episode yang telah diperkirakan berdasarkan wilayah dan negara untuk membantu perencanaan intervensi pencegahan dan manajemen kasus pada tingkat masyarakat dan fasilitas, termasuk vaksin dan antibiotic yang diperlukan dan penyalurannya. Hasil dari perkiraan ini ditampilkan pada tabel 211.

Tabel 2 memperlihatkan 15 negara dengan jumlah perkiraan tertinggi munculnya episode-episode pneumonia baru dan kejadian-kejadian lanjutannya. Negara-negara ini terhitung memiliki 74% (115.3 juta episode) dari 156 juta episode global. Lebih dari separuh kasus pneumonia tahunan baru terpusat pada hanya 5 negara dimana 44% dari anak-anak di dunia hidup: India (43 juta), China (21 juta), Pakistan (10 juta) dan di Banglades, Indonesia serta Nigeria (6 juta tiap-tiapnya). Perbedaan kejadian pneumonia klinis pada masa anak-anak di dunia pada tingkat negara ditunjukkan oleh gambar 111.


Penyebab Pneumonia Pada Anak (Etiologi)
Pneumonia klinis pada masa anak-anak disebabkan oleh kombinasi dari paparan terhadap faktor resiko terkait penjamu, lingkungan dan infeksi. Faktor-faktor resiko berkembangnya pneumonia terkait penjamu atau lingkungan terdapat pada Box 1.11

Studi-studi terdahulu dimana vaksin belum tersedia telah mengidentifikasi Streptococcus pneumoniae (pneumococcus) dan Haemophilus influenzae sebagai bakteri utama penyebab pneumonia, dengan beberapa kasus terparah disebabkan oleh Staphylococcus aureus dan Klebsiella pneumoniae19. Pada era modern, pemahaman mengenai penyebab pneumonia di negara-negara berkembang didasarkan 2 jenis studi. Jenis pertama terdiri dari studi prospektif berdasarkan rumah sakit yang bergantung pada kultur darah dan pada beberapa studi dari aspirasi paru percutaneous1. Beberapa studi lainnya juga menguji spesimen nasopharyngeal untuk mengidentifikasi virus. Pendekatan ini kurang sensitif untuk mengidentifikasi peyebab bacterial. Dengan mencoba untuk menambah metode kultur dasar dengan berbagai penanda penyebab bakteri tidak langsung secara luas tidak berhasil sebagai tes yang mampu membedakan antara kasus yang disebabkan oleh pneumococcus dan atau H. influenzae, yang biasa pada anak-anak di negara-negara berkembang, dan penyakit invasive.10 Jenis studi kedua adalah percobaan vaksin, dimana beban pneumonia dicegah dengan vaksin spesifik yang dianggap sebagai perkiraan terkecil dari beban pneumonia dikarenakan organisme yang dituju oleh vaksin.
Pada studi-studi prospektif berdasar mikrobiologi, bakteri penyebab utama adalah pneumococcus, yang teridentifikasi pada 30–50% kasus.19,8,18 Organisme yang paling sering terisolasi pada sebagian besar studi adalah H. influenzae tipe b (Hib; 10–30% dari kasus), diikuti oleh S. aureus dan K. pneumoniae. Selain itu, studi aspirat paru telah mengidentifikasi fraksi signifikan dari kasus-kasus pneumonia akut disebabkan oleh Mycobacterium tuberculosis, yang terkenal sulit untuk diidentifikasi pada anak.8 Sering terjadi kontroversi seputar peran dari 3 organisme penting, non-tipe H. influenzae (NTHI), S. aureus and non-typhoid Salmonella spp ini. NTHI ditemukan sebagai patogen penting pada studi aspirat paru di Papua New Guinea,18 sementara pada serangkaian studi aspirat paru dari Gambia, dan pada sebagian besar studi-studi berdasarkan kultur darah, Hib adalah tipe utama dari H. influenzae yang teridentifikasi Studi-studi di Pakistan menemukan NTHI sebagai kultur paling umum pada isolat darah tapi hal ini belum ditemukan dimanapun. Studi utama pertama yang menggunakan aspirasi paru pada lebih dari 500 anak di Chile, termasuk kontrol normal, menemukan S. aureus sebagai pathogen utama.11 Penemuan ini belum direplikasi pada studi yang lebih baru, meskipun demikian baru-baru ini studi WHO dari pneumonia sangat parah (hypoxaemic) di tujuh negara menemukan S. aureus pada 47 dari 112 kasus (42% dari kasus) dimana bakteri telah teridentfikasi, membuatnya menjadi penyebab terbesar kedua.2 Peran dari non-typhoid Salmonella spp.juga belum jelas. Studi-studi dari Afrika menunjukkan bakteraemia secara umum disebabkan oleh non-typhoid Salmonella spp. dan sering berasosiasi dengan malaria. Meskipun Graham et al. di Malawi telah mengimplikasikan non-typhoid Salmonella spp.11 Pada kasus-kasus radiologis pneumonia, peranan organisme ini pada pneumonia belum jelas, karena studi-studi kultur darah telah fokus pada anak-anak dengan demam dan nafas cepat sehingga mungkin telah mengidentifikasi anak-anak dengan bakteraemia.
Sementara itu pada studi-studi etiologi viral pneumonia menunjukkan bahwa respiratory syncytial virus (RSV) sebagai penyebab viral utama, yang teridentifikasi pada 15–40% kasus pneumonia atau bronchiolitis pada rumah sakit di negera-negara berkembang disusul oleh influenza A and B, parainfluenza, human metapneumovirus dan adenovirus.23 Studi terbaru juga telah memperkuat peranan virus respiratory syncytial sebagai patogen penyebab pneumonia yang sangat signifikan dan mematikan, secara tersendiri atau melalui infeksi gabungan dengan bakteri. Akan tetapi dikarenakan virus-virus ini bersifat fragile, dan sulit untuk diidentifikasi sehingga seringkali kurang dihiraukan. Kejadian viral pneumonia ini terutama mengalami puncak pada musim dingin di negara beriklim sedang dan pada musim hujan di negara beriklim tropis. Umumnya infeksi pernafasan oleh virus-virus tersebut meningkatkan resiko sekunder pneumonia bakterial dan infeksi viral atau bacterial lainnya. Hal ini seringkali ditemukan pada anak dengan pneumonia di negara-negara berkembang (kurang lebih 20–30% dari episode).11 Lebih jauh lagi, episode wheezing karena aliran udara reaktif sangat umum terjadi setelah episode-episode seperti itu, yang sebagian besar terjadi pada anak laki-laki dibandingkan perempuan pada tahun pertama kehidupan. Resiko pneumonia atau bronchiolitis yang disebabkan respiratory synctyal virus tertinggi pada anak dibawah usia 2 tahun dengan penyakit terparah terjadi pada bayi usia 3 minggu hingga 3 bulan.25 Hal ini menunjukkan bahwa usaha-usaha vaksinisasi dibutuhkan pada awal-awal kehidupan.
Pada tahun-tahun terakhir, epidemik HIV juga telah berkontribusi secara substansial pada peningkatan kejadian dan mortalitas pneumonia anak. Pada anak dengan HIV, infeksi bacterial masih tetap berperan sebagai penyebab utama kematian pada pneumonia, tetapi patogen tambahan seperti Pneumocystis jiroveci juga ditemukan pada anak terinfeksi HIV. Sementara M. tuberculosis tetap menjadi penyebab penting dari pneumonia pada anak dengan HIV dan yang tidak terinfeksi.11 Vaksin yang tersedia memiki kemanjran yang rendah pada anak dengan HIV, tapi masih dapat memberikan perlindungan dengan proporsi signifikan terhadap penyakit. Program-program Antiretroviral dapat mengurangi kejadian dan tingkat keparahan pneumonia yang berasosiasi dengan HIV pda anak melalui pencegahan terhadap infeksi HIV, dengan menggunakan co-trimoxazole prophylaxis dan perawatan dengan antiretrovirals.27
Organisme-organisme lainnya, seperti Mycoplasma pneumoniae, Chlamydia spp., Pseudomonas spp., Escherichia coli, dan campak, varicella, influenza, histoplasmosis dan toxoplasmosis, juga menjadi penyebab pneumonia. Sebagian besarnya belum dapat diatasi, tetapi imunisasi terhadap campak, influenza dan kemungkinan penggunaan bacille Calmette–Guerin (BCG) mungkin saja telah berkontribusi secara substansial pada penurunan beban pneumonia. Sedikit data yang tersedia mengenai penyabab neonatal pneumonia di negara-negara berkembang, tetapi studi-studi mengenai sepsis pada neonatal menunjukkan bahwa hal ini termasuk organisme-organisme Gram-negative enteric, khususnya Klebsiella spp, dan organisme-organisme Gram-positive, umumnya pneumococcus, Streptococcus Grup B dan S. aureus.20

Faktor Resiko
Beberapa keadaan seperti gangguan nutrisi (malnutrisi), usia muda, kelengkapan imunisasi, kepadatan hunian, defisiensi vitamin A, defisiensi Zn, paparan asap rokok secara pasif dan faktor lingkungan (polusi udara) merupakan faktor resiko untuk terjadinya pneumonia.3,12 Faktor predeposisi yang lain untuk terjadinya pneumonia adalah adanya kelainan anatomi kongenital (contoh fistula trakeaesofagus, penyakit jantung bawaan), gangguan fungsi imun (gangguan sistem imun terkait penyakit tertentu seperti HIV), campak, pertussis, gangguan neuromaskular kontaminasi perinatal dan gangguan klirens mucus atau sekresi seperti pada fibrosis kistik, aspirasi benda asing atau disfungsi silier (kapita).

Patogenesis dan Patofisiologi
Sebagian besar pneumonia timbul melalui aspirasi kuman atau penyebaran langsung kuman dari saluran repiratorik atas. Hanya sebagian kecil merupakan akibat sekunder dari viremia atau bakteremia atau penyebaran dari infeksi intra abdomen. Dalam keadaan normal saluran respiratori bawah mulai dari sublaring hingga unit terminal adalah steril. Paru terlindung dari infeksi melalui beberapa mekanisme termasuk pertahanan anatomi dan mekanis, juga sistem pertahanan tubuh lokal maupun sistemik. Pertahanan anatomi dan mekanik diantaranya adalah filtrasi partikel di hidung, pencegahan aspirasi dengan reflek epiglotis, pengeluaran benda asing melalui reflek batuk, pembersihan kea rah kranial oleh lapisan mukosilier. Sistem pertahanan tubuh yang terlibat baik sekresi local immunoglobulin A maupun respon inflamasi oleh sel-sel leukosit, komplemen, sitokin, immunoglobulin, alveolar makrofag dan sel perantara imunitas.7
Pneumonia terjadi bila satu atau lebih mekanisme diatas mengalami gangguan sehingga kuman pathogen dapat mencapai saluran nafas bawah. Inokulasi patogen penyebab pada saluran nafas menimbulkan respon inflamasi akut pada penjamu yang berbeda sesuai dengan pathogen penyebabnya.
Virus akan menginvasi saluran nafas kecil dan alveoli, umumnya bersifat tidak sempurna dan mengenai banyak lobus. Pada infeksi virus ditandai lesi awal berupa kerusakan silia epitel dengan akumulasi debris ke dalam lumen. Respon inflamasi awal adalah infiltrasi sel-sel berinti tunggal ke dalam submukosa dan perivascular. Sejumlah kecil sel-sel akan didapatkan dalam saluran nafas kecil. Bila proses ini meluas, dengan adanya sejumlah debris dan mucus serta sel-sel inflkamsi yang meningkat dalam saluran nafas kecil maka akan menyebabkan obstruksi baik sebagian maupun menyeluruh. Respon inflamasi ini akan diperberat dengan adanya edema submukosa yang mungkin bias meluas ke dinding alveoli. Respon inflamasi di dalam alveoli ini juga seperti yang terjadi pada ruang interstitial yang terdiri dari sel-sel berinti tunggal. Proses infeksi yang berat akan mengakibatkan terjadinya pengelupasan epitel dan akan terbentuk eksudat hemoragik. Infiltrasi ke interstitial sangat jarang menimbulkan fibrosis. Pneumonia viral pada anak merupakan predisposisi terjadinya pneumonia bakterial oleh karena rusaknya penghalang mukosa.3
Pneumonia bakterial terjadi dikarenakan masuknya patogen pada saat menghirup nafas. Terjadi tidaknya proses pneumonia tergantung dari interaksi antara bakteri dan ketahan sistem imunitas penjamu. Ketika bakteri dapat mencapai alveoli maka beberapa mekanisme pertahanan tubuh akan dikerahkan. Saat terjadi kontak antara bakteri dengan dinding alveoli maka akan ditangkap oleh lapisan cairan epithelial yang mengandung opsonin dan tergantung pada respon imunologis penjamu akan terbentuk antibody immunoglobulin G spesifik. Dari proses ini akan terjadi fagositosis oleh makrofag alveolar, sebagian kecil kuman akan dilisis melalui perantaraan komplemen. Mekanisme seperti ini terutama penting pada infeksi oleh karena bakteri yang tidak berkapsul seperti Streptococcus pneumonia. Ketika mekanisme ini tidak dapat membunuh bakteri pada alveoli, leukosit dengan aktifitas fagositosisnya akan direkrut dengan perantaraan sitokin sehingga akan terjadi respon inflamasi. Hal ini akan mengakibatkan terjadinya kongesti vascular dan edema yang luas, dan hal ini merupakan karakteristik pneumonia oleh karena pneumokokus. Kuman akan dilapisi oleh cairan edematus yang berasal dari alveolus ke alveolus melalui pori-pori Kohn. Area edematous ini akan membesar secara sentrifugal dan akan membentuk area sentral yang terdiri dari eritrosit, eksudat purulent (fibrin, sel-sel leukosit ) dan bakteri. Fase ini secara hispatologi dinamakan red hepatization (hepatisasi merah).3
Pneumonia merupakan suatu keadaan klinis, dimana paru-paru mengalami inflamasi dan gangguan pertukaran oksigen yang menyebabkan beberapa gejala seperti batuk-batuk dan kesulitan pernafasan, yang biasanya diakibatkan oleh infeksi.11,12 Tahap selanjutnya adalah hepatisasi kelabu yang ditandai dengan fagositosis aktif oleh leukosit . Pelepasan komponen dinding bakteri dan pneumolisin melaluibdegradasi enzimatik akan meningkatkan respon inflamsi dan efek sitotoksik terhadap semua sel-sel paru. Proses ini akan mengakibatkan kaburnya struktur seluler paru.
Resolusi konsolidasi pneumonia terjadi ketika antibodi antikapsular timbul dan leukosit meneruskan aktifitas fagositosisnya; sel-sel monosit akan membersihkan debris. Sepanjang struktur reticular paru masih intak (tidak terjadi keterlibatan interstitial), parenkim paru akan kembali sempurna san perbaikan epitel alveolar terjadi setelah terapi berhasil. Pembentukan jaringan parut pada paru minimal.7,14
Pada infeksi yang disebabkan oleh Staphylococcus aureus, kerusakan jaringan disebabkan oleh berbagai enzim dan toksin yang dihasilkan oleh kuman. Perlekatan Staphylococcus aureus pada sel mukosa melalui teichoic acid yang terdapat di dinding sel dan paparan di submukosa akan meningkatkan adhesi dari fibrinogen, fibronektin, kolagen dan protein yang lain. Strain yang berbeda dari Staphylococcus aureus akan menghasilkan faktor-faktor virulensi yang berbeda pula, dimana faktor virulensi tersebut mempunyai satu atau lebih kemampuan dalam melindungi kuman dari pertahan tubuh penjamu, melokalisir infeksi, menyebabkan kerusakan jaringan yang lokal dan bertindak sebagai toksin yang mempengaruhi jaringan yang tidak terinfeksi. Beberapa strain Staphylococcus aureus menghasilkan kapsul polisakarida atau slime layer yang akan berinteraksi dengan opsonofagositosis. Penyakit yang serius sering disebabkan Staphylococcus aureus yang memproduksi koagulase. Produksi koagulase atau clumping factor akan menyebabkan plasma menggumpal melalui interaksi dengan fibrinogen dimana hal ini berperan penting dalam melokalisasi infeksi (contoh: pembentukan abses, pneumatosel). Beberapa strain Staphylococcus aureus akan membentuk beberapa enzim seperti katalase (menon-aktifkan hidrogen peroksida, meningkatkan ketahanan intraseluler kuman) penicilinase atau β lactamase (menonaktifkan penisilin pada tingkat molekular dengan membuka cincin beta laktam molekul penisilin) dan lipase.3
Pada pneumonia terjadi gangguan pada komponen volume dari ventilasi akibat kelainan langsung di parenkim paru. Terhadap gangguan ventilasi akibat gangguan volume ini tubuh akan berusaha mengkompensasinya dengan cara meningkatkan volume tidal dan frekuensi nafas sehingga secara klinis terlihat takipnea dan dyspnea dengan tanda-tanda usaha inspiratori. Akibat penurunan ventilasi maka rasio optimal antara ventilasi perfusi tidak tercapai (V/Q < 50 =" 60" 40 =" 50" 30 =" 40">5 tahun 15-25 = 20

Perkusi toraks tidak bernilai diagnostik, karena umumnya kelainana patologinya menyebar. Suara redup pada perkusi biasanya karena adanya efusi pleura. Pada auskultasi nafas yang melemah seringkali ditemukan bila ada proses peradangan subpleura dan mengeras (suara bronkial) bila ada proses konsolodasi. Ronki basah halus yang khas untuk penderita yang lebih besar, mungkin tidak akan terdenganr untuk bayi. Pada bayi dan balita kecil karena kecilnya volume toraks biasanya suara nafas saling berbaur dan sulit diidentifikasi.7
Secara klinis pada anak sulit membedakan antara membedakan antara pneumonia bakterial dan pneumonia viral. Namun sebagai pedoman dapat disebutkan bahwa pneumonia bakterial awitannya cepat, batuk produktif, penderita tampak toksik, lekositosis dan perubahan nyata pada pemeriksaan radiologis. Namun keadaan seperti ini kadang-kadang sulit dijumpai pada seluruh kasus.21 Penggunaan BPS (Bacterial Pneumonia Score) pada 136 anak usia 1 bulan- 5 tahun dengan pneumonia di Argentina yang mengevaluasi suhu aksilar, usia, jumlah netrofil absolut, jumlah bands dan foto polos dada ternyata mampu secara akurat mengidentifikasi anak dengan resiko pneumonia bakterial sehingga akan dapat membantu klinisi dalam penentuan pemberian antibiotika.
Perinatal pneumonia terjadi segera setelah kolonisasi kuman dari jalan lahir atau ascending dari infeksi intrauterin. Kuman penyebab terutama adalah GBS (Group B Streptococcus) selain kuman-kuman gram negatif. Gejalanya berupa respiratory distress yaitu merintih, nafas cuping hidung, retraksi dan sianosis. Sepsis akan terjadi dalam hitungan jam, hampir semua bayi akan mengarah ke sepsis dalam 48 jam pertama kehidupan. Pada bayi prematur, gambaran infeksi oleh karena GBS menyerupai gambaran RDS (Respiratory Distress Syndrome).
Sementara itu di Indonesia program P2ISPA (Pemberantasan Penyakit Infeksi Saluran Pernafasan Akut) mengupayakan agar istilah Pneumonia lebih dikenal masyarakat, sehingga memudahkan kegiatan penyuluhan dan penyebaran informasi tentang penanggulangan Pneumonia. Program P2ISPA mengklasifikasikan penderita kedalam 2 kelompok usia:
- Usia dibawah 2 bulan (Pneumonia Berat dan Bukan Pneumonia)
- Usia 2 bulan sampai kurang dari 5 tahun (2 bulan - Pneumonia, Pneumonia Berat dan Bukan Pneumonia).
Klasifikasi Bukan-pneumonia mencakup kelompok balita penderita batuk yang tidak menunjukkan gejala peningkatan frekuensi nafas dan tidak menunjukkan adanya penarikan dinding dada bagian bawah ke dalam. Penyakit ISPA diluar pneumonia ini antara lain: batuk-pilek biasa (common cold), pharyngitis, tonsilitis dan otitis. Pharyngitis, tonsilitis dan otitis, tidak termasuk penyakit yang tercakup dalam program ini.
Diet Pada Pneumonia
Petunjuk untuk perawatan adalah untuk memberikan diet yang ringan, yang tidak akan merangsang batuk saat menelan, atau meningkatkan dyspinea dengan membuat perut kembung, atau memperbesar aktifitas jantung karena memerlukan tenaga pencernaan yang besar. Sebisa mungkin dihindari agar tidak dimuntahkan, dan jika terjadi mual, harus segera ditangani agar dapat dikendalikan. Tidak perlu untuk menjaga diet susu yang ketat, tetapi jika susu dapat diterima, disarankan untuk tidak memberikan yang lain selama gejala-gejala akut berlangsung; kecuali, air dadih, jus, broth, dan putih telur dapat diperbolehkan. Makanan berpati dan bersakarin (pemanis buatan) tidak boleh diberikan. Minuman dingin dapat diterima dan menguntungkan bagi pasien, dan air tawar atau yang telah teraerasi, seperti Apollinaris or air soda, dapat diminum dengan jumlah yang dapat dipertimbangkan. Hal ini dipercaya oleh beberapa ahli dapat mendukung aktifitas ginjal, dan mengurangi racun yang menyebabkan gejala-gejala pokok penyakit. Bagaimanapun, terdapat beberapa kasus diantara orang dengan sirkulasi yang kuat dan sehat, dimana serangan terjadi dengan sangat tiba-tiba dan hebat. Nadi penuh dan kuat, jantung sangat terbebani dengan usaha untuk mengeluarkan sejumlah besar darah yang belum teraerasi secara sempurna. Pada kasus-kasus sejenis, penambahan cairan dengan jumlah yang besar pada sirkulasi, melebihi asupan gizi yang dibutuhkan, dapat memiliki efek lebih lanjut mempertegang jantung.
Selain itu disebabkan bahwa air berkarbonasi mengurangi kekentalan dahak, yang seringkali sangat kental.
Diet sebaiknya dijaga tetap cair hingga defervescence telah terjadi, dengan suhu normal dan dimulai dengan hilangnya the exudation - in fact, lebih baik untuk memperpanjang pemberian dietiga atau empat hari setelah suhu tubuh kembali normal, untuk memastikan demam tidak kembali lagi. Pada kasus-kasus dimana resolusi tertunda, dan pasien menjadi semakin lemah, meskipun suhu tubuh mungkin mendekati normal, mungkin diinginkan memberi sedikit makanan padat lebih cepat, dan daging yang dimemarkan, roti panggang, atau telur yang dimasak setengah matang dapat ditambahkan pada diet susu.
Selama keseluruhan periode pemberian diet harus sangat bergizi dan mudah dicerna; susu masih mungkin diberikan, dan setelah secara perlahan kembali menjadi pengaturan makan 3 kali sehari27.

Diet Pada Broncho-Pneumonia
Broncho-pneumonia selalu penyakit yang kritis, dan perawatan sepenuhnya diperlukan pada perawatan dan pemberian makanan. Diet seharusnya terdiri dari beberapa jenis seperti daging giling, susu yang telah dicernakan sebelumnya, dan putih telur. Stimulasi dibutuhkan pada awal perawatan dan pada jumlah yang sangat diperlukan. Air dingin, sebaiknya diberikan secara sistematis, terutama kepada anak pada usia muda, yang belum mampu menyatakan keionginannya untuk minum. Susu panas dan Vichy, dengan perbandingan satu bagian Vichy untuk dua bagian susu untuk anak yang lebih tua, atau setengah-setengah untuk bayi, yang dapat memberikan efek melunakan lender dan mempermudah batuk. Jika terdapat kecenderungan flatulensi, air teraerasi lebih baik dihindari. Saat penyakit terjadi pada anak-anak, dietnya harus disesuaikan agar mengurangi beban organ dalam mencernanya. Pertama-pertama, makanan sebaiknya diberikan setiap dua jam, dan susu biasanya dibutuhkan. Selanjutnya dapat diselingi dengan penambahan putih telur, daging giling, ararut, atau egg albumin, expressed meat juice, plain beef or mutton broths, arrowroot, or other gruels.

Pencegahan
Pemberian imunisasi memberikan arti yang sangat penting dalam pencegahan pneumonia. Pneumonia diketahui dapat sebagai komplikasi dari campak, pertusis dan varisela sehingga imunisasi dengan vaksin yan berhubungan dengan penyakit tersebut akan membantu menurunkan insiden pneumonia. Pneumona yang disebabkan oleh Haemophillus influenza dapat dicegah dengan pemberian imunisasi Hib.
Pada Februari 2000, vaksin pneumokokal heptavalen telah dilesensikan penggunaannya di Amerika Serikat. Vaksin ini memberikan perlindungan terhadap penyakit yang umum disebabkan oleh tujuh serotype Streptococcus pneumonia. Penggunaan vaksin menurunkan insiden invasive pneumococcal disease.11 Penggunaan vaksin pneumokokal heptavalen secara rutin di Amerika Serikat ternyata mampu menurunkan bakteremia yang disebabkan Streptococcus pneumoniae sebesar 84% dan sebesar 67% untuk bakteremia secara keseluruhan pada populas anak 3 bulan- 3 tahun.
The American Aademic of Pediatric (AAP) merekomendasikan vaksinasi influenza untuk semua anak dengan resiko tinggi yang berumur 6 bulan dan pada usia tua. Untuk memberikan perlindungan terhadap komplikasi influenzae termasuk diantaranya adalah pneumonia, AAP juga merekomendasikan untuk semua anak usia 6 bulan sampai 23 bulan jika kondisi ekonomi memungkinkan.3
Selain itu berdasarkan penelitian terhadap bakteri utama penyebab pneumonia di negara-negara berkembang telah disimpulkan dua penyebab utama pneumonia bakterial yang dapat dicegah oleh vaksin adalah Hib dan pneumococcus.18,28 Pada dua penyebab tersebut, vaksin akan mencegah sebagian besar pneumonia yang disebabkan oleh dua bakteri tersebut.
Pencegahan lain dapat dilakukan dengan menghindari faktor paparan asap rokok dan polusi udara, membatasi penularan terutama dirumah sakit misalnya dengan membiasakn mencuci tangan dan penggunaan sarung tangan dan masker, isolasi penderita, menghindarkan bayi atau anak kecil dari tempat keramaian umum, pemberian ASI, menghindarkan bayi atau anak kecil dari kontak dengan penderita ISPA.3
Selain itu usaha penanganan berbagai faktor resiko yang berhubungan dengan masalah zat gizi adalah masalah yang juga sangat penting untuk diperhatikan. Penanganan kejadian malnutrisi seperti kekurangan energi protein, kekurangan mikronutrien akan dapat menurunkan tingkat keparahan penyakit ataupun memperkecil kemungkinan infeksi. Selain itu pemenuhan kebutuhan zat gizi juga terbukti dapat meningkatkan ketahanan imunitas sehingga kejadian paparan patogen yang dapat berakibat fatal dapat diperkecil.

Sesi Konsultasi
1. Anak saya sudah beberapa bulan ini sering mengalami sesak nafas, saya khawatir dia terkena pneumonia, bagaimana pendapat Ibu?
Saat ini usia anak Ibu berapa tahun usianya?
Sebentar lagi usianya 3 tahun
Sebelumnya, bisa Ibu jelaskan bagaimana kondisi kesehatan anak ibu saat ini?
Iya bu, anak saya itu sebenarnya kalau kelihatannya sih baik-baik saja, pertumbuhannya juga bagus, tidak kurang gizi, waktu pas lahir juga berat badannya normal, hanya saja satu bulan belakangan ini kadang-kadang malam harinya dia suka sesak nafas.
Selain sesak nafas apakah anak ibu juga mengalami demam, jantungnya berdetak cepat, dahak hijau yang keras?
Tidak ko bu, dia hanya sesak nafas saja.
Apakah di lingkungan tempat tinggal ibu atau ada diantara keluarga ibu yang terkena pneumonia ?
Setahu saya tidak ada bu.
Kalau begitu apakah Ibu sudah pernah memeriksakan anak ibu ke dokter?
Belum pernah.
Apakah imunisasi anak Ibu sudah lengkap?
Sudah ko sudah lengkap, bahkan sudah sempat di vaksin pneumonia juga.
Kalo begitu, sebaiknya dalam waktu dekat ini coba ibu periksakan ke dokter untuk mengetahui penyakit yang sebenarnya, sebaiknya juga dilakukan rotgen dan pemerikasaan laboratorium seperti dahak supaya penyebab penyakitnya lebih jelas. Tapi menurut pendapat saya. dilihat dari keadaannya, anak ibu tidak mengalami pneumonia.
2. Sebenarnya apa sih penyebab pneumonia?
Penyebabnya beragam, ada yang disebabkan oleh bakteri, virus, jamur, atau beberapa penyebab lain yang belum diketahui dengan jelas.
3. Kalau begitu bagaimana supaya tidak kena pneumonia?
Pertama-tama saat anak lahir usahakan untuk menyempurnakan seluruh imunisasinya dan juga karena sekarang sudah tersedia vaksin pneumokokal heptavalent untuk pneumonia. Berikan ASI eksklusif selama 4 bulan pertama, penuhi kebutuhan gizi dengan makanan yang beragam dan seimbang, Jaga kebersihan lingkungan terutama lingkungan bermain anak, hindari polusi udara dan asap rokok, dam hindiri kontak dengan penderita.


PENUTUP

Kesimpulan
Pneumonia adalah proses infeksi akut yang mengenai jaringan paru-paru (alveoli). Terjadinya pneumonia pada anak seringkali bersamaan dengan proses infeksi akut pada bronkus (biasa disebut bronchopneumonia). Gejala penyakit ini berupa demam, berkeringat, denyut jantung meningkat cepat, napas cepat dan napas sesak, karena paru meradang secara mendadak. Batas napas cepat adalah frekuensi pernapasan sebanyak 50 kali per menit atau lebih pada anak usia 2 bulan sampai kurang dari 1 tahun, dan 40 kali permenit atau lebih pada anak usia 1 tahun sampai kurang dari 5 tahun. Pada anak dibawah usia 2 bulan, tidak dikenal diagnosis pneumonia.
Pneumonia Berat ditandai dengan adanya batuk atau (juga disertai) kesukaran bernapas, napas sesak atau penarikan dinding dada sebelah bawah ke dalam (severe chest indrawing) pada anak usia 2 bulan sampai kurang dari 5 tahun. Pada kelompok usia ini dikenal juga Pneumonia sangat berat, dengan gejala batuk, kesukaran bernapas disertai gejala sianosis sentral dan tidak dapat minum Bibir dan kuku mungkin membiru karena tubuh kekurangan oksigen. Pada kasus yang eksterm, pasien akan mengigil, gigi bergemelutuk, sakit dada, dan kalau batuk mengeluarkan lendir berwarna hijau. Sementara untuk anak dibawah 2 bulan, pneumonia berat ditandai dengan frekuensi pernapasan sebanyak 60 kali permenit atau lebih atau (juga disertai) penarikan kuat pada dinding dada sebelah bawah ke dalam.
Pneumonia merupakan masalah kesehatan di dunia karena angka kematiannya tinggi, tidak saja di negara berkembang, tapi juga di negara maju seperti Amerika Serikat, Kanada dan negara-negara Eropa. Amerika Serikat misalnya, terdapat dua juta sampai tiga juta kasus pneumonia per tahun dengan jumlah kematian rata-rata 45.000 orang.
Di Indonesia, pneumonia merupakan penyebab kematian nomor tiga setelah kardiovaskuler dan tuberkulosis. Faktor sosial ekonomi yang rendah mempertinggi angka kematian. Gejala Pneumonia adalah demam, sesak napas, napas dan nadi cepat, dahak berwarna kehijauan atau seperti karet, serta gambaran hasil ronsen memperlihatkan kepadatan pada bagian paru. Kepadatan terjadi karena paru dipenuhi sel radang dan cairan yang sebenarnya merupakan reaksi tubuh untuk mematikan luman. Tapi akibatnya fungsi paru terganggu, penderita mengalami kesulitan bernapas, karena tak tersisa ruang untuk oksigen. Pneumonia yang ada di masyarakat umumnya, disebabkan oleh bakteri, virus atau mikoplasma ( bentuk peralihan antara bakteri dan virus ). Bakteri yang umum adalah Streptococcus Pneumoniae, Staphylococcus Aureus, Klebsiella Sp, Pseudomonas sp,vIrus misalnya virus influensa.
Akan tetapi saat ini persepsi global mengenai pneumonia sebagai masalah kesehatan umum dilemahkan dengan pencitraannya yang familiar dan mudah diatasi di dunia yang terindustrialisasi. Hal ini dapat diterima mengingat berbagai studi telah menunjukkan, meskipun pneumonia sebagai penyakit infeksi virus, bakteri,ataupun keduanya, pada kenyataannya, memang sebagian besar faktor resiko pneumonia adalah masalah yang umumnya dapat dihindari yang dapat diatasi. Selain itu masalah lain dari segi manajemen perawatan penderita pneumonia adalah kesenjangan akses fasilitas kesehatan dengan metode penanganan yang masih belum efektif secara pembiayaan.

Saran
Beberapa faktor resiko pneumonia seperti gangguan nutrisi (malnutrisi), kelengkapan imunisasi, kepadatan hunian, defisiensi vitamin A, defisiensi Zn, paparan asap rokok secara pasif dan faktor lingkungan (polusi udara) merupakan masalah yang umumnya dapat dicegah dan diatasi. Sehingga upaya pemberian pemahaman kepada masyrakat merupakan salah satu upaya yang perlu digalakkan. Suatu langkah yang bisa diambil sebagai upaya pencegahan dan penanganan penyakit ini adalah dengan merubah perilaku hidup masyarakat terutama dalam memilih makanan sehari-hari dan menghindari berbagai paparan seperti polusi dan asap rokok. Untuk dapat melakukan perubahan ini bisa dilakukan dengan pendidikan kesehatan berupa penyuluhan dan konsultasi gizi baik di rumah sakit maupun di masyarakat.






DAFTAR PUSTAKA
1. Adegbola. RA, Falade AG, Sam BE, Aidoo M, Baldeh I, Hazlett D, et al. The etiology of pneumonia in malnourished and well-nourished Gambian children. Pediatr Infect Dis J 1994;13:975-82. PMID:7845751.
2. Asghar R, Banajeh S, Egas J, Hibberd P, Iqbal I, Katep-Bwalya M, et al. Multicentre randomized controlled trial of chloramphenicol vs. ampicillin and gentamicin for the treatment of very severe pneumonia among children aged 2 to 59 months in low resource settings: a multicenter randomized trial (spear study). BMJ 2008;336:80-4. PMID:18182412 doi:10.1136/bmj.39421.435949.
3. Asih S. Retno, S. Landia, & MS. Makmuri 2006. Ilmu Kesehatan Anak XXXVI. Surabaya: UNAIR Press.
4. Baqui, A.H., et al. 2002. Effect of zinc supplementation started during diarrhoea on morbidity and mortality in Bangladeshi children: community randomized trial. BMJ. 325:1059.
5. Black, R.E. 2003. Zinc deficiency, infectious disease and mortality in the developing world. J. Nutr. 133:1485S–1489S.
6. Bobat, R., et al. 2005. Safety and efficacy of zinc supplementation for children with HIV-1 infection in South Africa: a randomised double-blind placebo-controlled trial. Lancet. 366:1862–1867.
7. Correa AG, Starke JR. 1998. Bacterial Pneumonias. Dalam: Chernick V, Boat F, penyunting. Kending`s Disorders of The Respiratory Tract in Children Philadhelphia: WB Saunders, 6: 485-503.
8. Falade AG, Mulholland EK, Adegbola RA, Greenwood BM. Bacterial isolates from blood and lung aspirate cultures in Gambian children with lobar pneumonia. Ann Trop Paediatr 1997;17:315-9. PMID:9578790.
9. Gittens MM. 2002. Pediatric Pneumonia. Clin Ped Emerg Med J (3):200-1414
10. Goldblatt. D, Miller E, McCloskey N, Cartwright K. Immunological response to conjugate vaccines in infants: follow up study. BMJ 1998;316:1570-1. PMID:9596595.
11. Igor Rudan,a Cynthia Boschi-Pinto,b Zrinka Biloglav,c Kim Mulhollandd & Harry Campbelle 2008. Epidemiology and etiology of childhood pneumonia. Bull. World health Organ. 86: 400-416.
12. J. Anthony G. Scott, W. Abdullah Brooks, J.S. Malik Peiris, Douglas Holtzman, & E. Kim Mulholland 2008. Pneumonia research to reduce childhood mortality in the developing world. J of Clinical Investigation. 118: 1291-1298
13. Makonnen, B., Venter, A., and Joubert, G. 2003. A randomized controlled study of the impact of dietary zinc supplementation in the management of children with protein-energy malnutrition in Lesotho. I: Mortality and morbidity. J. Trop. Pediatr. 49:340–352.
14. Miller MA, Ben T., Daurn RS. Bacterial Pneumonia in Neonates and Older Children. Dalam: Taussing LM, Landau LI, penyunting. Pediatric Respiratory Medicine. Philadelphia: WB Saunders, 17: 1432.
15. Preston, S.R., & Haines, M.R. 1991. Fatal years – child mortality in late 19th century America. Princeton University Press. Princeton, New Jersey, USA. 4–5.
16. Rudan, I., Tomaskovic, L., Boschi-Pinto, C., & Campbell, H. 2004. Global estimate of the incidence of clinical pneumonia among children under five years of age. Bull. World Health Organ. 82:895–903.
17. Rudan, Tomaskovic L, Boschi-Pinto C, & Campbell H. Global estimate of the incidence of clinical pneumonia among children under five years of age. Bull World Health Organ 2004;82:895-903.
18. Shann F, Gratten M, Germer S, Linnemann V, Hazlett D, Payne R. Etiology of pneumonia in children in Goroka Hospital, Papua New Guinea. Lancet 1984;2:537-41. PMID:6147602 doi:10.1016/S0140-6736(84)90764-5.
19. Shann. F. Etiology of severe pneumonia in children in developing countries. Pediatr Infect Dis J 1986;5:247-52.
20. The WHO Young Infants Study Group. Bacterial etiology of serious. infections in young infants in developing countries: results of a multicenter study. Pediatr Infect Dis J 1999;18 Suppl;S17-22. PMID:10530569 doi:10.1097/00006454-199910001-00004.
21. UNICEF. 2007. State of the World’s Children. New York: United Nations Children’s Fund.
22. WHO Programme for Control of Acute Respiratory Infections. 1990. Acute respiratory infections in children: case management in small hospitals in developing countries. A manual for doctors and other senior health workers. WHO. Geneva, Switzerland. 74 pp. 2.
23. Weber MW, Mulholland KE, Greenwood BM. Respiratory syncytial virus infection in tropical and developing countries. Trop Med Int Health 1998;3:268-80. PMID:9623927 doi:10.1046/j.1365-3156.1998.00213.x 38.
24. Weber, M.W., Palmer, A., Oparaugo, A., and Mulholland, E.K. 1995. Comparison of nasal prongs and nasopharyngeal catheter for the delivery of oxygen in children with hypoxemia because of a lower respiratory tract infection. J. Pediatr. 127:378–383.
25. Weisman LE. Populations at risk for developing respiratory syncytial virus and risk factors for respiratory syncytial virus severity: infants with predisposing conditions. Pediatr Infect Dis J 2003;22:S33-9. PMID:12671450 doi:10.1097/00006454-200302001-00005.
26. Williams, B.G., Gouws, E., Boschi-Pinto, C., Bryce, J., & Dye, C. 2002. Estimates of world-wide distribution of child deaths from acute respiratory infections. Lancet Infect. Dis. 2:25–32.
27. W. Gilman Thompson, M.D. Practical Dietetics. New York. D. Appleton & Co.
28. Zar HJ, Madhi SA. Childhood pneumonia – progress and challenges. S Afr Med J 2006;96:890-900. PMID:17077915.

Merkel on"Energy Source and Its Strategic Role For a Country"

A month after Russia cut off gas supplies to the Ukraine for the first time in 2006, Angela Merkel said that the European Union which gets 40 percent of its gas from Russia needed to develop a common energy policy over the next 15 years to guarantee supply security.

At the same time, Russian energy monopoly Gazprom, along with its German partners E.On and BASF-Wintershall, were deciding on "Nord Stream" as the name for a pipeline that would make Germany heavily dependent on Russia for energy for decades to come.
The European Union, meanwhile, is largely absent from this debate. Talk of a common energy market died soon after Ms. Merkel made her 2006 statement, but in Berlin, there has been little support for Merkel's concerns about overreliance on Russia.The nations continue to make deals that make them reliant on Russia for the long term. This tension between the recognized need for a common market and nations acting in their own long-term energy security interests is at the core of a growing European rift over how to deal with Russia.

Energy source however playing very significance role for each country and what Merkel concern over her country overreliance on Rusia its one of her visionary step for her country. We have all saw what happened to the world when ones of the important energy source such as the oil price increase. Higher oil prices since 1999 partly the result of OPEC supply management policies contributed to the global economic downturn in 2000-2001. Accordind to the report by The International Energy Agency on May 2004 the vulnerability of oil-importing countries to higher oil prices varies markedly depending on the degree to which they are net importers and the oil intensity of their economies. Eventough Germany has successfully become one of the strongest economy in the world but the fact that Germany is one of the largest importers of Russian gas will easily put a country in unstability once if Russian gas import isn`t available any longer.

My Comment`s of Dewi Soekarno

Well I got 10 for the Dewi Soekarno`s quiz, eventough to be honest at first I just knew her only as the Japanese widow of Indonesia's founding president Sukarno. Well anyway It is nice to know that many great things Dewi Soekarno have done through the years after her husband passed away. It must be very hard to her at the young age she has to move to a very new condition because and meeting with people that probably so much different with her life before. In fact at the time she got married, Indonesia right just declared its Independent and still far behind japan at several aspect, with of course many other new thing like culture. Through all that I think she is a very talented and smart woman that`s able to learn so many things and easily adapted in a new condition and environment.
Moreover I think she is also a good mother. I also read several article about her daughter with Soekarno named Kartika Sari Soekarno. Well she is also a good woman, today while her mother Dewi Soekarno active in several foundations helped people around the world her daughter continue to help many Indonesia through her foundation named Kartika Sari Foundation.

Lena Maria and Us

Born in Sweden to parents that always giving her full of support Lena Maria was very special from the start. The compassion and abiding love but never pity from her parents, have made she grown and turned became the remarkable girl who is today Lena Maria Klingvall, a woman of indomitable spirit and unshakable faith.

Lena learned to use her one fully formed foot to do all manner of things, from basic self-care to complicated matter like playing keyboards and driving a car with unceasing faith in her parents. She has shown her independent and remarkable spirit from early on, Lena refused "special" status, preferring instead to learn how to accomplish things her own way. In her own words, "I prefer to rejoice in what I can do-not mourn what I can't." In that spirit, Lena has not only learned to play keyboards and drive a car, but also to conduct a choir, develop a successful professional singing career and compete in the Paralympics in Seoul, Korea.
In youth she never scared for trying various sports and artistic activities. She excelled at swimming, representing her country at the 1988 Paralympic Games in Seoul. That the same year she visited Japan for the first time. Many Japanese impressed of her, It's quite something to be successful at both the arts and sports, and particularly so if you have physical disabilities. Known simply as Lena Maria in Japan, where she enjoys a large following, In the past decade, she has visited Japan nearly every year and performed in 45 of the nation's 47 prefectures. It is said that she often sings in Sweden, too, but has not achieved the celebrity status she has in Japan.

It is important to quote here that Lena Maria's disability did not stop her from trying various activities, even something thatmost of people with no handicap could not ever done. There must be a lot of factors lay inside the successful of Lena Maria but something I learnt as wonderfull factors from her are support, try and continue. There is a lot of extraordinary wonderfull thing happened when parents` love and support exists one of them is Hee Ah Lee from Korea she borned handicapped and have Lobster Claw Syndrome but with all love and wonderfull struggle and support from her mother Woo Kap Sun, she success become one of the pianist well known not only in Korea but also able to held several successful concert around Asia. The next are about try and continue, well many people wish and dream but only a few of them that finally do something in order to try, in order to change what they dream and wish into reality. Well let`s said many people tried but then less than the few I said you before after facing obstacle and failure were able to continue their “try”. I think that`s several things what makes someone like Lena Maria become different through her great achievements today.

Last but not least, Be brave and never give up for something you trust as your great and best dream you have that will be a great contribution you will be able to give in the future. One of the greatest person in my life once said that “what`s makes you a winner is not when you are winning, it is when you are failing then you able to stand up over and over again until the highest of your achievements, one day you`ll figure this out and when you do, you will change the world".

It Is Better To Light a Candle Than Curse The Darkness

Anna Eleanor Roosevelt was called "First Lady of the World." In the course of her life, ER became a leading figure on the issue of women's emancipation. Well before her life in the White House she was active in the Democratic Party and women's labor unions such as the Women's Trade Union League (WTUL) and the International Ladies Garment Workers Union (ILGWU). During the Second World War she became co-chair of the national committee on Civilian Defense and advocated for women's participation in the war effort. She incorporated these issues into a wider range of social and political concerns such as civil rights, human rights, youth and democracy.

Although ER was well known for all these huge society activity, at her early age she was a shy girl. Anna Eleanor Roosevelt was born in New York City in 1884. She was the daughter of Elliot Roosevelt, brother of future president Theodore Roosevelt, and Anna Ludlow Hall. Her father, although loving, was an alcoholic; her mother was cold and disapproving. By the time she was eight, both of her parents had died, so she went to live with her grandmother. Awkward and shy, she was sent to finishing school in England when she was 15. Here the withdrawn Roosevelt blossomed, excelling in languages and literature and becoming popular for the first time in her life.

When she returned to New York City at age 17, Roosevelt refused to take part in the activities of high society. Instead, she chose to work toward social reforms. She taught dancing and literature at community centers and visited needy children in the slums. Through her work, she gained an intimate knowledge of how the poor actually lived. During this time, she met her fifth cousin Franklin D. Roosevelt. Against his mother's wishes, they were married on March 17, 1905. Her uncle, President Theodore Roosevelt, gave her away at the wedding. Over the next ten years, she gave birth to six children (one died in infancy).

Neither her family nor her husband's growing political career prevented Roosevelt from pursuing her own social concerns. While he served in Washington as assistant secretary of the navy during World War I, she worked with the Red Cross. She visited wounded troops in the Naval Hospital and worked to improve conditions at a hospital for the mentally ill. After Roosevelt and her husband returned to New York in 1920, she became active in movements calling for equal rights for women and better working conditions for female employees.

In the summer of 1921, Roosevelt's life changed drastically. While vacationing on an island off the coast of Maine, her husband was stricken with an attack of poliomyelitis (polio). The disease left him permanently paralyzed from the waist down. Determined to maintain her husband's political links, she quickly learned public speaking and political organization. Over the next few years, she campaigned for Democratic candidates in New York and worked for the women's division of the party.

In 1928 Roosevelt's husband was elected governor of New York. She then became his "legs," inspecting state hospitals, prisons, and homes for the elderly. In 1932 he was elected to the first of four presidential terms, giving her a national platform from which to address her concerns. Roosevelt forever changed the role of the First Lady. She began holding weekly press conferences, speaking only to women reporters mainly on women's issues. In 1935 she started writing a column, "My Day," which appeared in national newspapers. For its first three years, "My Day" focused on the concerns of women. By 1939, however, Roosevelt was addressing general political topics in her column.

This change reflected the increasing role Roosevelt played in her husband's policy decisions. More than anyone in the White House, she brought the cause of the oppressed to her husband's attention. She championed the struggle of Appalachian farmers to reclaim their land, and she made sure African Americans were receiving relief from New Deal programs. Throughout her reign as First Lady, she argued against all forms of discrimination. Roosevelt was especially concerned with the condition of America's youth during the Depression. In 1935 she helped found the National Youth Administration, which gave thousands of high school and college students part-time work.

It used to be said that all that time she was her husband ears, and eyes but it was never not as simple as all that for one thing she was her husband wife and had to take that consequencies. Today looking to her biography everybody realizes that It was uneasy life year by year for Eleanor Roosevelt. The marriage was not easy but was never broken. The relationship between husband and wife took a sharp turn in 1918. It was a defining moment when ER discovered that her husband had been having an affair with her former social secretary Lucy Mercer. The romantic aspect of her marriage ceased to exist, but her husband’s political ambitions made divorce impossible. She dicided stayed together with her husband and established a completely new relationship. Became in many respects his representative to the outside world when, for example, he was unable to travel.

Being the wife of an successful politician brought many possibilities, but ER had always been careful not to inhibit or contradict her husband's objectives, and set careful parameters for her conduct. The circles that Eleanor was raised in cast her in the role of helpmate wife. This position should have placed her outside of the political arena. The day that FDR was elected, November 8, 1932, ER was happy for her husband but feared the responsibilities that she would have to bear as manager of the White House household. Lorena Hickok, a journalist and friend with whom ER possibly had an amorous relationship, quoted ER in her 1962 book Eleanor Roosevelt, Reluctant First Lady as saying after the 1932 presidential elections: "For him, of course, I'm glad--sincerely. I could not have wanted it any other way. After all I'm a Democrat, too. Now I shall have to work out my own salvation. I'm afraid it may be a little difficult. I know what Washington is like, I've lived there." Immediately the national spotlight moved to follow ER, and she had to make changes in her life that she resisted strongly. But through all that she believe that “It is better to light a candle than curse the darkness”, better for her for always fighting for the greater good of society that would lead many people into solution and better world rather than just cursing uncomfortable she felt inside. This own choice to fight for the greater good of society coupled with any others outside influences produced a powerful mix that resulted in Mrs. Roosevelt, the First Lady of formidable political stature.

BUTET MANURUNG

The Person

Saur Marlina Manurung was born on February 21, 1972 in Jakarta the capital city of Indonesia. Her nickname “Butet” is a name that given by her family since she is the first daughter of “Batak” tribe family. She has been obsessed with indigenous peoples ever since she was a child. National Geographic was her favorite magazine, and she dreamed about becoming an explorer. She is a huge fan of Harrison Ford’s Indiana Jones. The movie inspired her to use the teaching technique of learning through playing.
Butet was an excellent student, excelling in mathematics and an accomplished pianist—though she pursued these achievements out of a sense of obligation. Then her life took a sudden turn as she entered university and her father passed away. In college, she studied anthropology and education, and she finally had a chance to explore the world. An avid member of the Nature Lover’s Club, and eventually acting as its head, she became an expert hiker, rafter, and cave explorer. And on her expeditions she finally had the chance to meet firsthand the peoples she had previously encountered only in print of National Geographic magazines or on television.
She wrote her thesis on the relationship between traditional village leaders and government-installed functionaries in West Timor. As she developed her own interests, she supported herself by teaching piano, and today credits her father with imparting to her the discipline and perseverance that would shortly become crucial to her success.
Upon completing her degrees, she could actualy have had a well-paid, prestigious job in Jakarta instead, but this is simply not an option for her. Butet took what seemed to her a dream job: going to the forest to set up an education program with a remote tribe of hunter-gatherers, part of a conservation organization’s strategy to work with local communities.

The Problem
Indigenous peoples tend to evoke two strong opposing viewpoints. Because they live in fragile ecosystems, they are alternately viewed as its best defenders and worst enemies; as rightful inhabitants and dangerous encroachers; as a vigilant monitor and powerless victim of environmental catastrophe; as barometers of ecological diversity and as mere footnotes to major economic and political conflicts. In Indonesia, the paradox extends into a moral realm. To some, including much of the citizen sector, indigenous peoples are symbols of pristine nature, cultural
diversity, and gentle, simple living. While to others, including at times the state, they represent poverty, backwardness, and an embarrassingly primitive obstacle to progress. “Anak Dalam” tribe, is the indigenous peoples that live in Bukit Dua Belas region, National Park in Jambi Province, about 225 km Westside Jambi in Sumatra Island, Indonesia. The tribe that Butet first decided to dedicate her nobel work.
The tribe “Anak Dalam” people like many other indigenous peoples in Indonesia have often been cheated when dealing with outsiders. Apparently, one such outsider once came to them with a piece of paper, claiming it was a letter of appreciation from the local subdistrict head, and asked them to sign it. They did, and were promptly evicted from their land. The letter was actually a land deed, and they had unwittingly sold their land.
Education is a long-term solution to such problems, but there are significant technical obstacles. The state has been slow to setup schools in remote areas, in part because few teachers are willing to go there. Where schools do exist, the curriculum and teaching style hardly fit with local customs. The structure of a school day, rote lessons, and a uniform national curriculum are simply adapted the modern world way of life. At the end most projects to set up remote schools fail.
Indonesia does have a national network for indigenous peoples, but actually this body has very few active members who come from indigenous communities. Most are representatives from citizen organizations working on environmental protection and culture. Butet recounts a story of an organization that spent several years trying to win over forest peoples to its conservation agenda. When that failed, the organization went ahead and made a forest management plan in the name of the local tribe without their input or consent. The zoning plan ignored the way that people actually use the forest, and the strong cultural beliefs that guide their actions. When the community found out, it vowed not to cooperate and a conflict, usually the end will be violence.
Butet knew those problems and there was a best solution for them, but it comes to nothing without implementation. So she dicided to unlearn everything she thought she knew about education. She was unfazed by the fact that none of her predecessors in the role had made any headway, and that the latest died of malaria contracted in the jungle, she just tried to simply focus on living with the community.

Long Way For a Headway
Certainly, her job is noble and demanding, but it just simply because of “Anak Dalam” peoples simple mind and limited access to education they regard reading and writing as something related to black magic, and to master black magic, they must make an offering. The situation that made her way for a headway even harder,
so then she dicided to find another way spent more days with the people of “Anak Dalam”.
However the reality is not that simple. Armed with blackboards, chalk and some pens and paper, and she has to walks long distances every day to teach the various sub-groups of the isolated “Anak Dalam” tribe. This is not easy to travel on foot in a 60,500 hectare tropical forest. Even when she finally finds one group, is not sure that she will be accepted. If a group rejects her, she goes and finds another group, which may mean another long journey. If a group welcomes her, she encounters another set of difficulties: how to persuade them to learn to read, write and count? And what is the most suitable teaching method?.
Furthermore she must also adjust herself to a different sense of time. For example, when they are hungry, they go hunting. If she wants to spend time with them, she has to go along. She also has to trained herself emotionally and psychologically strong enough to immerse themselves in a totally alien culture. She ever inadvertently break a local taboo and suddenly be asked to leave the community for a time. She realized that she has to be perceptive enough to read the situation, sensitive enough to abide by the community’s wishes, yet strong enough to return and ask to be accepted back in.
It was a long struggle for Butet until one day, “Anak Dalam” children happened to hear Butet recite some of their verses from memory and were surprised that an outsider could quickly learn their traditional verses by heart. The children told her that their tribe had thousands of ancestral verses, but after several generations, many of these verses had been lost as they had not been written down. Then they ask she to record the verses and then teach them how to transcribe them. They started to show their interest in reading and writing. Something that made Butet realized then that children, with their natural curiosity, were most receptive to her presence. So then she shelved the curriculum and spent her days playing with the children, letting them teach her about their community and life in the forest. As the children took a greater interest, Butet looked for opportunities to teach them to read, write and count. After 6 years of intensive work with forest communities and the organizations that want to serve them, Butet crystallized her own vision for connecting with indigenous youth and make another long run to solve the problems of many Indigenous people in Indonesia.

Butet Manurung “A Woman of Letters”
After spending years of teaching in “Anak Dalam” tribe, in 2001 she became the recipient of the Man and Biosphere Award from the Indonesian Institute of Sciences (LIPI) and UNESCO, the United Nations Educational, Scientific and Cultural Organization. Beside that she also awarded as the 1st Women of the year in Education by one of Indonesia Television Station.
Although she has made great achievements, she still hopes for more. She wants to prepare young indigenous people to help their communities make informed and
dignified choices about how they will cope with change. The first step is to provide basic education—literacy and comprehension of the wider world. Since the school system does not extend into remote areas, Butet is creating a national volunteer service named “Sokola” to place teachers in remote communities. Based on her own experience teaching in the forests of Sumatra, today Butet has developed a completely new method that allows people from pre-literate societies to quickly learn to read and write Indonesian. While Butet believes in the power of education in general, she is also scouting for young people who can begin building bridges between their communities and the many outside interests they now face. Her organization runs a program that brings youth from indigenous communities into national forums discussing natural resource use, forests, and forest communities.
So far, her organization Sokola working with a number of groups around Indonesia, who are facing a variety of challenges. The challenges that have convinced the members of Sokola that education for indigenous groups needs to be aimed at what those groups need. It also needs to be delivered in a much more flexible manner than the government system can provide. Rather than seeing nomadic or isolated indigenous groups as naked primitives who need modern schooling and a modern religion, they see them as needing appropriate forms of education, support, and protection as they face the challenges of adapting to a world which is encroaching on them from all sides. The challenges made them realize that for most modern society Butet with her Sokola just a committed group of volunteers. But for many Indigenous peoples out there the need for the kind of education they provide is very great

Sources
Anonimous 2006. Butet Manurung The Profile.http://www.ashoka.org [May 15, 2010]
Rokhdian Dodi 2008.Jungle Schools: Valunteers bring alternative education to marginalized communities. http://www.insideindonesia.org/edition-92/jungle-schools [May 15, 2010]
M. Bambang 2003. Butet manurung, Champion of Literacy. The Jakarta Post: Thursday, 11/20/2003.http://www.thejakartapost.com/news/2003/11/20/butet-manurung-champion-literacy.html [May 21, 2010]
Tedjasukmana Jason 2004. Butet Manurung A Woman of Letters. http://www.time.com/time/asia/2004/heroes/hbutet_manurung.html [May 21, 2010]
Tuti & Liska 2009. Saur Marlina Manurung. http://www.myhero.com/go/hero.asp?hero=SAUR_MARLINA_MANURUNG_Indonesia

Indira Gandhi

Indira Gandhi (November 19, 1917 - October 31, 1984).

Early life
She was the only child of Jawaharlal Nehru, the first Prime Minister of India. She was born on November 19, 1917 in Allahabad. She was born in family that was at the centre of Indian freedom struggle. Indira had a lonely childhood. Her father was often absent from being jailed so their communications are mostly through letters, and her mother was bed-ridden from tuberculosis, a terrible disease affecting the lungs and bones. Shortly after her mother's death in 1936, Indira enrolled at Santiniketan University and Somerville College, Oxford University, in England.
Indira Gandhi married a Parsi named Feroze Gandhi in 1942. Shortly after their marriage both Indira and Feroze Gnadhi, were arrested and jailed for nationalist activities. During her imprisonment Indira taught reading and writing to prisoners. Indira Gandhi was released after eight mounts and Feroze Gandhi after an year. After the release Feroze became editor of The National Herald, a newspaper founded by Jawaharlal Nehru, and Indira became the principal confidant and assistant of father during the period of Nehru`s prime ministership (1947-1965). Feroze Gandhi died in 1960. They had two sons, Rajiv and Sanjay.
When her father died in 1964 She was elected as a member of Parliament in her father's Indian National Congress Party, and was appointed a minister of Information and Broadcasting in the cabinet of Lal Bahadur Shastri who became Prime Minister after the death of Jawaharlal Nehru. This position was the fourth highest ranking position in the Cabinet. Many Indians were illiterate. Therefore, radio and television played a major part in informing them. As minister, she most importantly encouraged the making of inexpensive radios and started a family planning program.

As Prime Minister
After Shastri's death in 1966, Indira Gandhi was elected leader of the Congress Party in Parliament (the governing body of India) and became the prime minister until India held the next election. She was selected by party bosses in a thought that she was a compromise candidate that they could easily manipulate. In her initial days as a Prime Minister, Indira Gandhi encountered numerous problems such as famine, labour unrest, and misery among the poor in the wake of rupee devaluation; and agitation in Punjab for linguistic and religious separatism. In the forth elections held in 1967, She won and became one of the first women ever elected to lead a democracy of India.
Meanwhile, after twenty years of political dominance, the Congress Party was experiencing serious difficulty. Gandhi immediately set about reorganizing the party to make it a more effective instrument of administration and national development. Her goal was to achieve a wider measure of social and economic justice for all Indians. Her left-of-center policies (slightly liberal, or supporting civil liberties and social progress) became clear when Indira Gandhi became assertive and opt for a series of choices that pitted her against the Congress Party high command. She pursued a vigorous policy in 1969 of land reform and placed a ceiling on personal income, private property, and corporate profit to eradicate poverty. She also nationalized (brought under the control of government) the country's fourteen leading banks in a highly popular move meant to make credit more available to agriculture and to small industry.5.The congress expelled her for “indisciplines” on November 12, 1969 an action that split the party into two fraction; the Congress for organization (O)-led by Morarji Desai, and the Congress for Indira (I)-led by Indira Gandhi.
Indira Gandhi campaigned fiercely on the slogan of “Garibi Hatao” (eliminate poverty) during the general elections in March 1971 and won an unprecedented two-third majority. Her leadership qualities came to the fore during India-Pakistan war in 1971, where India's intervention enabled local separatists to crown their nine-month war of independence with the creation of the independent republic of Bangladesh. India achieved decisive victory over Pakistan in the face of diplomatic opposition from both China and the United States and lack of International support from almost every oher nation except the Soviet Union and Eastern Bloc countries. Indian victory over Pakistan led to great surge in Indira Gandhi`s popularity and she was compared to Goddess Durga by ordinary Indians, conquering Empress of India.
Expectation raised by the garibi hatao campaign and India victory over Pakistan in 1971 let to great dissapoinment in the mid-1970s. Enormous economic cost of 1971 war, increase in world oil prices and drop in industrial output added to the economic hardships. During this time a civil disobedience movement against Indira Gandhi was Iniated. In June 1975, Gandhi was found guilty of violating election laws and High Court invalidated her 1971 election. Instead of resigning, to secure her power and because of escalating riots, on June 26, 1975, Indira Gandhi declared a state of emergency which limited the personal freedom of Indians. Also, she ordered the arrests of the main opposition leaders. In her opinion, her dictatorship was for the good of India but people seen this action as Indira`s brand of ruthless politic. The daughter of Indian original democrate Jawahaharlal Nehru became India`s great dictator.
In early 1977 she suddenly decided to leave the emergency. Some says she did it because she was assailed by her own conscience other says because she was convinced she would win the next election. But in 10.free elections 1977 Indian people voted her out of office.

End of Career
The following year Gandhi headed the Congress Party as she returned to Parliament. In 1979 she again became prime minister. Indira's later reign was most marked by a serious breakdown in Hindu-Sikh relations that would eventually lead to her own assassination. Alarmed at the rise in popularity of the highly political Sikh missionary and leader Jarnail Singh Bhindranwale, India's leaders were disturbed by his proclamation that Sikhs were a sovereign and self-ruling community. Fearing Pakistani support for the movement, in June 1984 Gandhi ordered Operation Blue Star, a military assault on Amritsar's holy Harimandir Sahib or Golden Temple, the central Sikh place of prayer, which had been occupied by Jarnail Singh and his militant supporters with a heavy cache of arms. The occupiers refused to depart peacefully and a firefight ensued - with 83 soldiers and 493 occupiers killed, and many more injured.
Sikh alienation was deep and had dramatic consequences: on October 31, 1984, Indira Gandhi was assassinated by her two Sikh bodyguards, one of whom was fatally shot and the other subsequently (1988) sentenced to death by hanging. She died shortly after arriving at the All India Institute for Medical Sciences, AIIMS, in New Delhi.

Sources

Ali, Tariq. An Indian Dynasty: The Story of the Nehru-Gandhi Family. New York: Putnam, 1985.
Indira Gandhi Biography http://www.notablebiographies.com/Fi-Gi/Gandhi-Indira.html
Jayakar, Pupu. Indira Gandhi: An Intimate Biography. New York: Pantheon Books, 1993. http://departments.kings.edu/womens_history/igandhi.html
http://clevergames.wordpress.com/learning-the-spirt-from-indira-gandhi