Ascariasis is widespread over many Asian countries. In the D.I. Jogjakarta infection with Ascaris lumbricoides is very frequently found in children. As a cause of death however this disease is of little importance. In the section: Intestinal disturbances (Table VII-7) 3 patients are mentioned who died very probable by ascariasis and one patient who certainly died by ascariasis. As the complications of severe ascariasis mostly lead to operative treatment, we checked the number of patients who were treated by operation because of ascariasis during the period July 1, 1954 till july 1, 1958 in Bethesda Hospital at Jogjakarta. The surgeons during this period were G.J.Renes and prof. M.Salim. It appeared that in this period of 4 years only 6 patients were operated on because of ascariasis, while the annual average of the number of great operations was 829 in this period. This frequency is considerably lower than Fernando, mentioned for Colombo, Ceylon. In the Children’s hospital at Colombo 50 patients. Aged from 10 months till 10 years, were admitted during the period June 1954 till July 1956 because they needed surgical treatment. Forty-four patients out of these 50 were between 1½ and 4 years old. The complications of ascariasis observed in Colombo were intestinal obstruction, volvulus, intussusception, perforation of appendix, small intestine or Meckel’s diverticulum. Among these 50 patients 23 died of the complication of ascariasis. A survey of the patients who needed surgical treatment in Bethesda Hospital in the four year period mentioned above, is given in table IX-6.
It appeared that ascariasis was no important threat to children’s lives in the D.I. Jogjakarta. The patient who certainly died of ascariasis is mentioned in table IX-6, while the patients who very probably died of ascariasis were three boys aged 2½, 3 and 5 who were admitted in a serious general condition which did not allow surgical intervention. These patients died within 36 hours after admission.
The diagnosis intestinal obstruction by a lump of ascarisworms was made during the clinical examination and based on anamnesis and the examination of the stools.
In the University- and Bethesda children’s ward 40 patients aged under 10 were admitted because of ascariasis during the period July 1, 1954 till July 1, 1958.
Most patients were aged between 3 and 6. Out of these patients 5 needed surgical intervention, see table IX-5. Eight patients were admitted with incomplete obstruction of the intestine and could be cured without operation.
Table IX – 6.
Survey of the 6 patients suffering from ascariasis and needed surgical intervention during July 1, 1954 till July 1, 1958 in Bethesda hospital, Jogjakarta.
Table IX – 7.
Age distribution of 40 patients, admitted in two children’s wards at Jogjakarta because of ascariasis.
In these cases the complaints disappeared after removing 93 – 443 adult worms by giving a vermifuge (Santonin, Piperazinecitrate). The other 24 patients admitted in hospital because of complaints such as vomiting, colicky abdominal pains, while sometimes a sausage-shaped mass could be palpated in abdomen. These patient were suspected to suffer from ascariasis and made a bad impression at the moment of admission. During the period of admission the complaints disappeared after a vermifuge but the number of worms that passed was less striking than in the 8 patients mentioned above. All these patients were discharged in good condition.
In order to make an estimate of the percentage of children who were infected with ascaris lumbricoides in the different age groups we checked 871 patients who visited the out-patients-department of Bethesda Hospital during the period 1956-1957. Most of these patients visited this department because they suffered from diarrhoea. The stools were examined because these patients were suspected to suffer from bacillary dysentery and the result infection with ascar is was adventitious because it needed no extra effort to look at the same slide for ascaris eggs. However from the stools, which were examined only specimens which contained mucus were used. The results of this examination are shown in table IX-8.
The stools of these patients were therefore arbitrarily selected.
A second group of patients we also examined for infection with ascaris lumbricoides. This second group consisted of 3,379 patients who were admitted in the University- and Bethesda’s children’s wards during the period July 1, 1954 till July 1, 1958. Apart from the disease for which the patients were admitted the stools of all these patients was examined, because we liked to be informed of the quality of the stools of every patient who was admitted in the ward. The results of this examination is also mentioned in table IX-8.
The youngest child who had ascaris eggs in the stools was 52 days old. In this case the infection must have happened very probably in the first weeks after birth.
The percentage of ascaris infection is in the second group higher than among the first group of patients. In both groups of patients only the first examination was taken into account for this investigation. The number of ascaris eggs ranged from a few till dozens of them per field of microscopical option. We suppose that a systematic and more thorough examination of the stools of these patients would have resulted in higher figures of the infection-rate. However this was impossible under the local circumstances. Brug (1920) investigated the distribution of intestinal parasites in Djakarta. He repeated the examination of the stools of all persons involved in his investigation several times. It appeared from the first examination that 71% of these persons were infected with intestinal parasites, while from the second and third examinations this percentage appeared to be higher.
From the figures regarding the children we examined in Jogjakarta, it appears that the percentage of infected children gradually increases in the first years of life. In the second half year of life the percentage is 16%. In the fourth year of life the percentage of the infected children is 72%, while the infection rate does not increase after the fourth year of life. At this age a saturation seems to be reached in which according to a single examination of the stools the percentage of infected children appears to be 72%
Very probably all the children of the population in the D.I. Jogjakarta are infected with ascaris lumbricoides around the 5th year of life. The arrangement of the patients according to place of residence did not demonstrate a difference in infection rate between children living in the rural and urban areas of the D.I. Jogjakarta.
Table IX – 8.
Survey of infection-rate with ascaris lumbricoides of 871 out patients and 3,379 patients, admitted in two children’s wards at Jogjakarta during July 1, 1954 till July 1, 1958.
The very high infection-rate is no reason for astonishment because the conditions for infection with ascaris eggs are ubiquitous in Java. Some of the conditions which favour the spread of this disease are:
- The lack of sewerage in the whole city. Not all houses of the city are connected with the sewerage.
- Outside the towns well-built and well-used latrines are rather rare.
- The compounds of the houses are heavily infected with ascaris eggs and these compounds are the places where the children play and trot about.
- The loose, slightly moist ground with a temperature above 15ºC and plenty of oxygen are favourable for the development of the ascaris eggs. In these grounds the eggs remain infective for a long time.
Because these conditions circumstances are propitious for frequent infections with embryonated eggs in these regions where fecal contact is so intensive.
Data about the occurrence of ascariasis in other regions of Indonesia are rather scarce. Flu (1918) and Brug (1920) made an investigation about ascariasis among adult persons in Djakarta. The first investigator found that among 941 persons 43.8% had ascaris eggs in their stools. Brug demonstrated that 35% of the 250 soldiers examined had ascaris eggs in their stools. The most recent investigation was done by Marseille in the Tanah Tinggi district of Djakarta in 1938. The result of this investigation are mentioned in table IX-9.
This investigation concerned 1,000 persons divided into three age-groups. The stools were examined once but 4 smears were made from every specimen, viz. Three prepared with eosine-solution and one without adding special preparations.
Table IX – 9.
Result of the investigation of Marseille into the occurrence of ascariasis among the population of the district Tanah Tinggi in Djakarta (1938).
In Sulawesi Kayser examined in 1931 the stools of 271 children and 729 adults of the Mandanese coastal population. The children were aged 0-15. It appeared that 81.7% of these persons were infected with ascaris.
In the period after 1953 several reviews were published about the occurrence of ascariasis in Asian countries (Jeliffe, 1953; Stransky, 1955; de Silva, 1957; and Fermando, 1958). It appears from these publications that ascaris is common in China, Japan, Korea, Okinawa, the Philippines, Ceylon and the Indian Union.
Besides the necessity for surgical intervention in a number of the patients suffering from ascariasis it is of more importance that ascariasis often occurs in undernourished children. Ascariasis can have a disturbing influence on the digestion and resorption of foodstuffs in the intestine (Venkatachalam, 1953; Jeliffe, 1953; Stransky, 1955). The adult worms are able to produce the anti-enzym ascarase, which can disturb the activity of trypsine and pepsine and therefore the digestion of protein. The protein, which the ascaris needs for its growth from larva to adult worm, for the production of eggs and for its normal metabolism is taken from the protein available in the intestine. For a healthy well-nourished child these small losses of protein are not very important but for under-nourished children living on a diet poor in protein and near the level of minimal subsistence these losses are important and the “hospitality” given to a great number of intestinal parasites is a luxury which these under-nourished children cannot afford.