In the literature about the occurrence of diphtheria in Java the first published data are of diphtheria in Kediri (East Java, 1897) published by van Buuren, and later in Djakarta (de Haan, 1902) and Surabaia (Essed, 1925-1926).
A survey of the bacteriology and pathology of diphtheria in Indonesia by Kirschner in 1929 mentioned the occurrence of diphtheria among the urban population of Semarang (Central Java) and Bandung (West Java), both among the Indonesian and the European part of the population during the period 1924-1927.
In Bundung postmortem examination also included a bacteriological examination especially of the Indonesian children who died while membranes were present in the throat and mouth. This postmortem examination showed that diphtheria among Indonesian children was not a rare thing. 27 out of 42 cases of diphtheria leading to death in 1927 in Bandung were thus discovered. As a rule Indonesian parents came to the physician for help very late in the course of the disease or did not come at all. This phenomenon described for Bandung also occurs in Jogjakarta today. The parents, who come to ask for modern medical treatment for their children, are a minority of the population. The discovery that diphtheria is a frequently occurring disease in any region coincides in some cases with the opening of a bacteriological laboratory. This happened e.g. In Djakarta and in Bandung.
About the occurrence of diphtheria in the D.I. Jogjakarta the oldest data are mentioned by J.H.Maasland in his report of delegation(1936). He mentioned that in preceding decades no epidemics of diphtheria occurred, but that sporadic cases were observed every year. In the period July 1, 1954 till July 1, 1958 diphtheria was frequently observed as already appeared from table VOO-7, where is mentioned that in this period 61 children died of diphtheria in the two children’s wards concerned. In the group of 206 children, who died of infectious diseases, 100 died of tetanus, i.e. 48%, while the children who died of diphtheria made 29% of this group.
In the period mentioned above 190 patients suffering from diphtheria were admitted to the University-and Bethesda Children’s wards at Jogjakarta. The age distribution of these 190 patients is given in table IX-18. Most of these patients appeared to be aged less than 8.
Table IX – 18
Age distribution of the 190 diphtheria patients, admitted in two children’s wards at Jogjakarta in the period July 1, 1954 till July 1, 1958.
Because the facilities for bacteriological examination of the corynebacterium are available in Jogjakarta, swabs of the throat and mouth of the patients admitted because of suspected diphtheria to the two children’s wards, were sent to the central laboratory. From the University children’s ward in the period July 1, 1954 till July 1, 1958 45 swabs were sent and 18 times corynebacterium diphtheria could be isolated. This was also the case in 54 of the swabs sent for bacteriological examination from the Bethesda children’s ward. In 118 cases of diphtheria the diagnosis was not based on the result of a bacteriological examination either because this examination was negative or because it was not made.
In 25 out of these 118 cases where no bacteriological examination was made, the smear coloured according to Neisser showed corynebacterium on microscopical examination. The other cases were diagnosed as diphtheria based only on the clinical manifestations and anamnesis. Out of these 190 patients 61 died i.e. 32%.
Arranged according to place of residence it appeared that 88 of them lived in the city, 51 in kabupaten Sleman, 42 in kabupaten Bantul, 5 patients in Kulon Progo and 4 patients in Gunung Kidul. This distribution tallies with that of all the patients admitted during this 4-year period.
Popular knowledge of this disease is very seldom present with the mother. As a rule mothers take their children to hospital because of clear symptoms, such as progressive stridor, hoarseness, membranes on lip and tongue, bad general condition or bloody nasal discharge. It appeared that the prognosis of patients with membranes on lip and tongue, which is mostly a symptom in an early stage of the disease, was better than that of children admitted with laryngeal diphtheria. Out of 60 patients who were taken to hospital because the mother worried about membranes on tongue or lip only 8 died, i.e. 13%. Out of 72 patients suffering from hoarseness and/or stridor by laryngeal complications of diphtheria 41 died, i.e. 56%. These patients developed clear symptoms in a later stage of the disease, therefore the mother waited longer before taking the child to hospital.
The treatment of these patients was : 20,000 – 60,000 units of antitoxin according to the surface of the membranes; additional penicillin was given for 6-10 days. The experience with tracheotomy in patients suffering from severe stridor was disappointing. Mostly these patients had suffered from hypoxia rather a long time before admission could take place. Out of the 19 patients who were treated with tracheotomy only 2 survived.
As a complication of diphtheria we observed three patients suffering from complete hart-block. This diagnosis could be confirmed by the changes in the electrocardiogram. In two out of these three patients corynebacterium could be isolated from the swab of throat and mouth. All three patients died.
The epidemiology was never investigated in the D.I. Jogjakarta. Only in Djakarta a detailed investigation was made into the epidemiology of diptheria in the period 1939-1941 by Dinger and co-workers. Some data which resulted from this inquiry we like to quote here. The Tanah Tinggi district of Djakarta, where 26,000 inhabitants lived, was chosen as a test area. In the above mentioned period of 2½ years only 12 cases of diphtheria were observed. The investigation was forcused on
a: the occurrence of corynebacterium in the throat of unselected healthy
persons.
b: the occurrence of corynebacterium in nose, conjunctivae, infected ears,
infected wounds of infants and toddlers.
c: the proportional distribution of Schickpositive and Schicknegative persons in
a number of age-groups.
ad a: Among 4,114 healthy Indonesians it appeared that in 4.23% corynebacterium
could be isolated from the throat, while in 0.75% virulent corynebacterium
could be isolated. The highest frequency was found among the children.
ad b: The finding of corynebacterium in the nose, conjunctiva, ear secretion and
septic wounds of infants and toddlers demonstrated that this organism
occurred in 2.8%, 4.3%, 11.5%, and 34.1% of the cases respectively.
ad c: The Schick test was made in a great number of infants and children. The
result of these extensive investigation is mentioned in table IX-19a and 19b.
Table IX – 19a.
Sensitivity to Schick-test in 343 infants of chiefly Indonesian race during the first year of life and of Indonesian toddlers and schoolchildren in Djakarta.
Table IX - 19b
Percentage corynebacterium-carriers among healthy Indonesian persons of different age-groups living in Tanah Tinggi district at Djakarta in 1939 – 1941.
When the percentage of Schick positive children, i.e. The children who have na antitoxin against diphtheria toxin in their blood is compared in the age groups between 0 and 12 years we note that the percentage of Schick positive children rapidly diminished in the course of the years, especially in the group of boys. In this period many children developed antitoxins in their blood. At the end of the 6 year of life only 34% had not yet antitoxins in their blood demonstrable by this test. At the end of the 13th year of life this concerned boys in only 2.6% and girls in 22.5% of the cases. When school children of different social levels were compared, it appeared that the lower classes (Indonesians mostly) had a lower percentage of Schick positive children, while in the higher classes (European) this percentage was much higher. The percentage were at the age of 9 and 10 years 5% and 69% Schick positive respectively. Among the Indonesian children it was very probable that around the sixth year of life the greater part of the schoolchildren had already acquired immunity against diphtheria by subclinical infections of throat, nose, ears and skin injuries. The greater percentage of Schick positive girls which was observed in the different age groups and in the different social groups was explained by the fact: “that boys mingle more freely with the outer world and have a better change of acquiring a natural antidiphtheria immunity than girls”.
When we compare the clinical data obtained in the children’s wards of Jogjakarta with the result of Dinger’s investigation we note that the greater part of the patients in Jogjakarta were found in the age group with the highest percentage of Schick positive persons, viz. ½-5 years of age. Out of the 190 patients admitted in the Jogjakarta children’s ward 173, i.e. 91% was aged ½-5 year. Only three patients were aged less than 6 months, and 14 children were aged 6-10. The youngest patients were aged 2 weeks, 2 weeks and 5 months respectively. The bacteriological examination of the two patients aged two weeks was positive. Also in Jogjakarta it is very probable that many latent infections with corynebacterium happen without clinical symptoms, so that nearly everybody obtains immunity against corynebacterium before his eleventh year of life. Patients of over 10 of Indonesian nationality suffering from diphtheria were not found in Jogjakarta.
Besides the detailed investigation of Dinger and co-workers some other inquiries into diphtheria in Indonesia are made by other investigations.
In 1926 Smits applied the Schick test on 500 Javanese labourers in Sumatera (east coast region). It appeared that 95.6% of these plantation labourers were Schick negative. The percentage of 100 Javanese children, aged 4-6 appeared to be 60-75%.
In 1928 van de Walle applied the Schick test on 1895 schoolchildren in Bandung. It appeared that in the age groups of 5 and 6 years 34% was still Schick positive, while in the age groups of 10 – 16 years this percentage was decreased to 10%.
In 1933 van den Hoven van Genderen made an investigation into the titer of antitoxin against diphtheria in the blood of newborns, schoolchildren and adults at Bandung. He demonstrated that the titer of these antitoxins was in the blood of 106 newborns the same as in the blood of the mother. He demonstrated antitoxin in the blood of
- 90% of 41 boys aged 6-9 of the Sundanese race.
- 71% of 31 girls aged 6-9
- 97% of 74 boys aged 10-17
- 87% of 54 girls aged 10-17.
This was also the case in 99% of 300 male adults and in 97% of 200 female adults.
Most persons examined had a titer above 0.1 Antitoxin unit per cc serum.
In 1957 Hoogendoorn investigated the factors which influenced the age distribution of the diphtheria patients in the different provinces of the Netherlands, for the age distribution was not the same in all the provinces of this country. It appeared that the occurrence especially in the younger age groups was connected with a higher population density, because this enhanced the chances of infection out side the family and also with the presence of large families, because this enhanced the chance of infection within the family. These two conditions are present all over the urban and rural parts of the D.I. Jogjakarta, so the the circumstances in this region are favourable for the spread of corynebacterium.
A systematic vaccination against diphtheria never happened in Jogjakarta. With the limited quantity of antigen inoculations were only sporadically given to children who had been in contact with patients or at the request of the mother.