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Malaria

In the period between the first and second world war malaria in Java has been the subject of extensive investigations many times. Many publications in medical literature concerning malaria in Java and in other parts of Indonesia testify to this. However in the district of D.I. Jogjakarta no extensive, systematic investigation has taken place in this period before the second world war, as to

  • the occurrence of malaria in the different parts of this district;
  • the seriousness of infection among the resident population;
  • types of the Anopheles, of importance for transmission of malaria, and their breeding-places.

For our orientation as to the spread of malaria in the different parts of D.I. Jogjakarta we were dependent on a short survey written by Dr. J.H. Maasland in his report of delegation of 1936 and upon reports of the Malaria-Fighting Service, which started a systematic investigation in this area after the second world war. In pre-war years during the period April 1935 – October 1936 an examination of schoolchildren was done in a few quarters of the town and in 22 various ketjamatans of the D.I. Jogjakarta, as to the occurrence of enlarged spleens. In town a few hundreds of schoolchildren were examined and, in the 22 ketjamatans, 50 schoolchildren on an average perketjamatan. A high spleen index proved to be found only in parts situated along the south-coast, namely the southern part of the kabupaten Kulon Progo and of the kabupaten Bantul. Here spleen-indices were found varying from 22.4 (Pandjatan) – 50 (Pundong) – 64 (Srandakan) – to 100 (Temon).
From this very limited inquiry it was clear, that especially the south-coast was a very serious malaria district, whereas the people in other part of the district were distinctly less infected with malaria. This outcome agreed with the data from the policlinics where in the areas outside the coastal fringe malaria patients occurred only sporadically, in opposition to the policlinics in the coastal strip, where many patients came to be examined. In the month of may 1939, following a diet inquiry in the kabupaten gunung Kidul, a medical investigation was made in the same areas where the diet research was done, to wit in the ketjamatans Palijan, Nglipar, Ngawen, Pondjong, Semanu and Tepus. In 855 adult persons a parasiteindex was found lower than 1% and a spleen-index lower than 1%. In 1,295 children a parasite-index was found of ± 1% and a spleen-index of 0.5%, from which it was clear that in this area malaria was of little consequence.
In the years 1955-1957, as an orientation regarding the seriousness of malaria infection among the population in various kabupatens of D.I. Jogjakarta and in the town, an extensive examination took place executed by the survey-team of the above mentioned Service.
Blood of babies and of children aged 1 – 9 was examined as to the occurrence of malaria plasmodies and in the last group also as to the occurrence of an enlarged spleen. The data assembled in this investigation served as an orientation as to the spread of malaria in this region and at the same time as material for comparison to watch the effect of defensive measures taken in the period 1955 – 1958. The defensive measures consisted in spraying with insecticides the inner walls of dwellings. These measures were taken in the years after 1956 in the coastal district along the Indian Ocean and in the periphery of the city of Jogjakarta. In the other parts of D.I> Jogjakarta no measures were taken for fighting malaria. A survey of the data obtained concerning the parasite-index of babies and the spleen-index in children of 1 – 9 years old, before malaria fighting began, have been mapped in diagram 23.

Fig. 23.

Survey of the spread of malaria in the D.I. Jogjakarta (1955 – 1957)

Survey of the spread of malaria in the D.I. Jogjakarta (1955 – 1957).
The black part of the rounds figures corresponds with the percentage of children with enlarged spleen observed during the survey in these areas (see also table IX-16).

Table IX – 16.
Survey of the spread of malaria in the D.I. Jogjakarta in the period 1955 – 1957 (expressed in parasite-index and spleen-index per ketjamatan).

Survey of the spread of malaria in the D.I. Jogjakarta

From these surveys it is evident, that in the whole area of D.I. Jogjakarta malaria occurs endemically. In general the spleen-index is higher than the parasite-index in children of 1 – 9 years old examined. Only in some groups of children the parasite-index was higher than the spleen-index; there are 2 areas in evidence where malaria occurs in a higher intensity namely:

  • The south-coast, of the kabupaten of Kulon Progo, which has been mentioned as a region heavily infected with malaria already in former publications (J.H. De Haas, 1936, R. Soedigdo, 1937, 1938). At the 1957 investigation, which unfortunately took place after D.D.T. Had once been sprayed in the houses in 1956, spleen-indices appear to be high (varying from 28 – 51%).
  • In the kabupaten of sleman especially the southern partwas clearly infected with malaria very seriously (spleen-indices varying from 10 – 63%). In this sawah-district the population evidently has most to suffer from malaria. In 7 out of 10 ketjamatans the children’s (spleen-index was 46 – 63%)

In Gunung Kidul spleen-indices were low, mostly lower than 10. The data as to the parasite-index of babies in the various townships were not available.

Malaria vectors.

Though only little can be said with certainty about the vectors deciding the epidemiology of malaria in the area of D.I. Jogjakarta, because provisional investigations have not yet given elucidation in these aspects of malarial epidemiology. Yet there are clear indications of what kind of Anophelines may be of importance in the fight against malaria. Anophelines occurring in Jogjakarta are the following: A.aconitus, A.annularis, A.barbirostris, A.hyrcanus var. X(venhuisi), a.kochi, a.leucosphyrus, A.maculatus, a.minimus, flavirostris, A.schüffneri, a.subpictus subpictus, A.subpictus malayensis, A.ludlowi var.sundaica, A.tesselatus, A.vagus. Anophelines to be considered as vectors are: along the south-coast A.ludlowi var. sundaica, and in a lesser degree A.subpictus subpictus and A. aconitus, whereas in the mountain districts also A.maculatus received consideration. The reasons for suspecting exactly these Anophelines to be vectors of malaria in this district are the following: The Anophelines mentioned occur in great numbers in the districts concerned and have been found infected with sporozoites at earlier researches elsewhere in Java. Though in the course of 1952-1957 many mosquitoes have been found in the houses of the city of Jogjakarta, of the kabupatens of sleman, Bantul and southern Kulon Progo by the catchers of the Anti Malaria-Fighting-Service, which were then determined, while many thousands of specimens have been dissected, no infected specimens have been met with.
In the period 1952 – 1956 the team of the Malaria control Project, headed by Sudararaman, and sponsored by the W.H.O. And the Indonesian government, made an extensive inquiry after the vectors of malaria in the province of Central Java. In view of the very great similarity between the geographical proportions and the mosquito-fauna in this area and that of D.I. Jogjakarta, the results obtained seem to be of great importance also for the study of malaria-epidemiology in the region of D.I. Jogjakarta. In Central Java A.sundaicus, A.subpictus subpictus, A.aconitus and A.maculatus proved to be malaria vectors. Few persons acquainted with publications about malaria in Java will be surprised, that the strip along the south-coast is an area of endemic malaria. As most important vector in the whole coastal strip of Java has been found A. ludlowi var.sundaica.

A. ludlowi var.sundaica.

This anopheles laysits eggsalmost exclusively in stagnant, brackish water in shadowy places. Fresh-water sundaicus has not been met with in Java up till now. The optimal salt-percentage lies between 4-15%. Along the coast they find fit breeding-places in sufficient quantity. Especially along the coastal strip of kabupaten Kulon Progo they are regularly found in great numbers. Fish-ponds such as are found on Java’s north-coastand which mostly serve this Anopheles for breeding-places, are not extant in the region of d.I. Jogjakarta. But in the silted up river-mouths of Kali Glagah, Kali bogowonto in kabupaten Kulon Progo larvae of A.ludlowi are found in their lagoons up to 3 km away from the coast. From the research by the team of the Malaria Control Project (W.H.O.) executed during the period 1952-1956 in the province of Central Java, it appeared that in the period of August till December more A.ludlowi var.sundaica were caught in the houses than in other months of the year. In this period 143,207 female anophelines were caught during 6,996 catching-hours in houses situated along the south-coast of the province of Central Java; the anophelines caught were spread over the various species as follows: A.sundaicus 23.5%, A.subpictus 23.4%, A.subpictus malayensis 47.1%, other species 6.0%. The danger of A.ludlowi var.sundaica in transferring malaria is based principally in the following properties:

  1. It is easily infected by malaria plasmodies (esp. falciparum and vivax).
  2. It has a special preference to feed on human blood (Walch 1932, Sundararaman 1957).
  3. It is a house-gnat, very often staying in the house after having stung.
  4. At 6 o’clock in the evening it is already flying about, rendering the use of a mosquito-net ineffectual. However most A.ludwi var.sundaica feed between midnight and 5 o’clock in the morning (Sundararaman et al. 1957). Almost wherever this Anopheles was found in Indonesia in the years before worldwar II, it proved to be infected with malaria plasmodia.

In the period 1952 – 1956 on the south-coast of the province of Central Java 38,164 A.ludlowi var.sundaica were caught. 100 of which appeared to contain sporozoïtes when dissected. So the sporozoïtes index was 0.26%. Infected anophelines sundaicus were caught in all calendar months of any year, but in greater numbers in the second half of the year. In 22,896 A.subpictus the sporozoïte rate was 0.055%. Positive dissections were only found in 1953 and 1954.
A.sundaicus can fly over a distance of some km., so the zone of its reach for transferring malaria-plasmodiae is 1-3 km. Father land inward than any brackish breeding-place situated farthest from the coast.

A. aconitus.

In the region of D.I. Jogjakarta, situated father than 3-6 km. Away from the A.ludlowi brackish breeding-places, Anophelines aconitus and in a lesser degree Anophelines maculatus are considered as most probable vectors. These two anophelines use fresh water as breeding-places. A.aconites broods in plains as well as in hilly country along the banks of rivulets. As breeding-places it sometimes uses irrigation-conduits in bad repair, but the most important breeding-places of A.aconitus are sawahs. Two to three weeks after the planting of padi in the sawahs larvae were already found and afterwards until harvest time the sawahs were used as breeding-places; that means three entire months. A.aconitus larvae are but seldom found on the rice seed-beds (Walch, Soesilo, 1929).
A.aconitus larvae appeared to occur also in the small “impoldered” pieces of land along banks of rivers running through the city and used for growing vegetables (swamp cabbage).
In Java A.aconitus was found for the first time as a transmitter of malaria during an inquiry by Swellengrebel in Modjowarno (1919, East Java) and later on in the Tjihea plain (West Java) by Mangkoewinoto in 1923. It was in the Tjihea plain, where malaria infection was very serious among the population, that: 1) a regular and good repair of irrigation conduits, 2) a simultaneous sowing and harvesting of rice to the effect that after havest-time the rice-fields fell dry,-both measures prescribed by a watering and planting-regulation from authority, - proved to be effectual for the seriousness of malaria infection among the population. In a few years a great reduction in the number of new infection could be perceived. The circumstance that in the sawah regions of Sleman and Bantul, and in some parts 5 times every two years, padi is planted, entails that the peasants – in trying to get a maximum profit from the available sawah-ground – every peasant sows, plants and harvests according to the quality of the soil and the availability of irrigation-water. The lack of a simultaneous planting- and harvesting-time, after which the wawahs may fall dry till the next planting-time, gives to A.aconitus a good opportunity for breeding in these regions in any month of the year. In the period 1952-1956 in the province of Central Java, 32,050 female anophelines have been caught in the houses of the area of Bruno, north of Purworedjo during 1895 catching hours in the daytime.
Of these 70% were A.aconitus, 23.4% A.subpictus malayensis and 6.6% A.barbirostris and A.vagus. Of 9,944 A.aconitus dissected 9, that is 0.09% proved to contain Sporozoïtes. Of 41,280 A.subpictus malayensis dissected no one was found infected, nor anyone of the other 5 anophilines species. In practically all parts of the province of Central Java A.aconitus was found as a malaria vector in the period of 1952-1956. (sundararaman et al. ‘57). A.aconitusssucks the blood of both man and animal, but by preference animal blood (cow, buffalo) for food, so that in areas where there are few cattle and many people, such as in the case in the sawah districts Sleman and Bantul, people run a great risk to be often stung by A.aconitus. The flying range of A.aconitus probably is not very large. (± 350 meter was found as the greatest distance by Mangkoewinoto in a very limited test in the Tjihea plain made in 1923). Mangkoewinoto thought it to be very probable that A.aconitus entered the houses especially late at night to suck blood, and after that flew away to stay outside during the daytime, in bushes on the banks of rivers (Venhuis 1942).

A.maculatus.

A.maculatus prefers to breed in sunny spots, in waterwells in mountainous regions, in vegetation by riversides and small swamps along running mountain rivulets. In brooks of the Menoreh mountains (Kulon Progo) and on the slopes of Merapi larvae of A.maculatus have been found in 1955. In the city of Jogjakarta larvae of A.maculatus have been found a few times also in Kali Tjode and Kali Winongo, running down from the slope of Mount Merapi through the city. In default of small brooks as breeding places A.maculatus also puts up with sawahs, where in that case it breeds under the same circumstances as A.aconitus. Up to a height of 1,000 meter above sea-level A.maculatus and A.aconitus are found. That A.maculatus can transfer malaria in Java was established with certainty by Walch and Soesilo in 1929. during a violent malaria out burst in Batoer (Banjumas, Central Java), where A.maculatus proved to be infected (Infection rate 3 to 135 mosquitos). While A.aconitus also occurred in the same region and was found not to be infected. A.maculatus stings people by preference between 9 in the evening and 2 in the morning. They do not stay in the house but after having stung they escape outside. In the daytime these mosquitos stay in bushes and on the brinks of rivulets, in places where it is dark and where the kali has a rapid or a fall, i.e. In places where a high humidity prevails (as apparent from investigations by Venhuis in East Java, 1941).
In 1952-1956 A.maculatus was found much less frequently in Central Java than A.aconitus. Only in Kedu, west of D.I. Jogjakarta, these anophelines were found to be infected (Sept.1956). While in the same region A.aconitus too appeared to be infected.
In Bethesda hospital, on the northern boundary of the town, where many patients from the city of Jogjakarta and the kabupatens of Sleman and Bantul come for treatment, 500 – 600 malaria patients per year came for attendance. The data concerning the malaria patients diagnozed and treated at the policlinic of Bethesda hospital during the period July 1, 1954 – July 1, 1958 we assembled in a survey as follows:

As the blood of practically every patient with fever both at the policlinic and in the wards is examined as to the occurrence of malaria plasmodien at the laboratory which works accurately under expert and experienced leadership (chief J.Henuhilli), it is improbable that the diagnosis of malaria should have been missed in a number of cases worth mentioning. During this period an action for fighting malaria was started by a service expressly founded for the purpose in 1955. The measures taken consisted in once a year spraying the walls of the houses situated in the 10 kemantrens of the city of Jogjakarta bordering on the edge of the town. The four kemantrens centrally situated (Kraton, Danuredjan, PakuAlaman, Gondomanan) were left untouched. From August 20, 1955 till October 1, 1958 the houses in 10 “boundary”-kemantrens have been sprayed with D.D.T. 2, 3 or 4 times. It was not possible to spray all houses, as a small number of inhabitants refused the sprayings, because it had happened that hens and ducks were killed by it, which meant a severe loss for this poor population. In kabupaten sleman and in kabupaten Bantul (excepted the narrow strip along the south-coast) in this period no measures were taken for the fighting of malaria. The influence of these measures upon the number of patients visiting the policlinic in Bethesda hospital during July 1, 1954 – July 1, 1958 is demonstrable in table IX-17.

Table IX – 17.
Survey of 1788 malaria-patients, who were treaded in the out-patients-department (total 1,022 patients) and in the hospital Bethesda (total 756 patients) during July 1, 1954 till July 1, 1958.

Survey of 1788 malaria-patients

The number of malaria patients resident in town decreased after 1955. in the first half of 1954 and in 1955 these patients made up 53% of all malaria patients treated, while in the first half of 1958 this was only 20%. Plasmodium falciparum was found to be the originator in 1,048 malaria patients out of 1,788 observed in these 4 years, that is in 59% of the cases. In 36% of the cases plasmodium vivax and in 4% plasmodium quartana was found to be the originator. In 0.9% ( = 16 cases) a double infection was found, to wit 12 times malaria quartana and once malaria tertiana and malaria quartana.
The age distribution of these 1,788 malaria patients was as follows:
Out of the total number of malaria patients

  • 6% were infants
  • 14% were toddlers
  • 12% were schoolchildren
  • 68% were adults.

Though Bethesda hospital is situated in a region with serious endemic malaria, there is a relatively low mortality from malaria.
Of 495 malaria patients younger than 10 years treated in Bethesda hospital in these 4 years there died:

  • 11 infants
  • 8 toddlers (1-4 years)
  • 5 schoolchildren (5-9 years)

which means a mortality of 4.8%.
Of 1293 malaria patients over 10 years 16 died. In this age group that means a mortality of 1.2%. In 15 cases it was malaria tropica and in only one case malaria tertiana. The mortality is counted for all malaria cases, whereas only the case-history of the malaria patients admitted (45% of all malaria patients) was know.
As in general the serious patients were admitted, we suppose that mortality among the policlinical malaria patients treated has been very low or absent.
In the Gadjah Mada children’s ward in the period May 1, 1955 till July 1, 1958 died of malaria in total 3 toddlers and 1 schoolchild.
Of the 11 babies who died in Bethesda hospital in 2 cases it concerned inborn malaria. Those were the only 2 cases of malaria congenitalis we set eye on during this period. We mention the short case histories here below:

SUMARDJA was born May 5, 1956 with the assistance of a dukun. On May 11, 1956 the 6 days old icteric little boy was taken to the clinic with tetanus neonatorum, which had started with a trismus after a 5 days incubation time. The child weighed 2,800 grammes and after admission apparently also suffered from malaria tertiana. In the thick preparation made from a blooddrop, many malaria tertiana schizontes were apparent. The same day the mother’s blood was inspected as t malaria parasites, which proved to be negative. The mother told us that during the fourth month of pregnancy she had suffered from a feverous illnes with cold shivers. The child had frequent and heavy attacks of tetanus and died 20 hours after admission. We registered this case of decease under: Tetanus neonatorum.

SOETIKNAR, born Sept. 19, 1956, while his 17 year old mother was suffering from an attack of malaria tropica. The weight at birth was 2,100 grams. On his second day of life in the morning no malaria plasmodien were found at a fevertop as high as 39°C., but at a second test in the afternoon of Sept.20 in this praemature neonatus malaria tropica rings were present in the blood. The therapy consisted in 100 mg of euchinine per day during 7 days, after which no more malaria-plasmodies were apparent in the blood. As no breast feeding was available, this praemature was fed with buttermilk, which had an unsatisfactory result, after which we passed on to give protein-milk, also without success. The child died on its 18th day of life. We considered malaria tropica as the “underlying cause of death”.

The other 10 deaths of babies caused by malaria concerned; first 7 babies brought in to the clinic during an attack of malaria fever and who died in the ward within 2 times 24 hours after admission. Their age was respectively 17 days, 3 months, 4 months, 5 months, 7 months, 9 months and 10 months. In 5 cases it concerned malaria tropica and in 2 cases malaria tertiana. The 17 days old baby might have suffered from a malaria congenitalis, but as its age surpassed the shortest time of incubation, being 7 days, and infection after birth may also have been possible. The other 3 deaths with malaria in babies concerned in all 3 cases bad-nourished babies, which in the bad general condition has favoured decease. The first case was a baby of 85 days old with a weight of 2,150 gr. Who had had, after the mother’s decease 10 days postpartum, only tea and maizena-water to drink from the grandmother until it was 60 days old, after which it had received a much too thin solution of cow’s milk as only food. It died 3 days after admission from an attack of malaria tropica.
The second case was an 8 months old baby suffering in addition to malaria tropica also from a serious malnutrition. The bodyweight was 4,500 gr. Its decease during an attack of malaria tropica we consider to be favoured by malnutrition also in this instance.
The third case was a praemature child of 55 days old with a weight of 1,800 gr., which during its short life had received too little breast-feeding, and died in an attack of malaria tertiana.
Of the 8 toddlers dying from malaria:

  • 3 were 1 year old.
  • 1 was 2 years old.
  • 4 were 3 years old.

All 8 case concerned a malaria attack elapsing with lightning speed and all 8 patients died within 24 hours after admission, while the children had been ill at home for only 1-4 days.
In 2 cases malaria comatosa was concerned.
In 3 cases a fever convulsion was the reason, that the parents took the child to hospital.
Also the 5 schoolchildren, who died in consequence of a malaria infection, died within 24 hours after admission. Four children of 6 years old died of malaria tropica, 2 of whom were admitted while in coma. Here too the duration of the disease before admission was only 2-4 days. The 9 years old, who died from malaria tertiana within 24 hours after admission, died in a state of acute confusion.
As a rule a malaria patient recovers.
Only one few very acutely passing malaria infection offering practically no possibilities for treatment ended in death from malaria. The treatment we gave was euchinine 300 mg. Per year of life up to a maximum of 1 gr. Per day, during 7 days, and this praitically always led to recovery. We refrained from a systematic thereapy to preclude relapses into malaria tertiana. After dismissal the children without exception were agin exposed to new infections, because measures for personal prophylaxis against malaria are for this population much too expensive and the need of it is not felt. Only in a few cases of resistency of the plasmodies against euchinine and in one case of idiosyncrrasy of the patient with respect to euchinine, we used nivaquine with favourable results.
The 3 pre-school children, who died from malaria in the children’s ward of Gadjah Mad University, died likewise within 24 hours after admission, namely 2 from malaria tropica and 1 from malaria tertiana. The only child of school-age, that died in this clinic, suffered at the same time from many congenital aberrations in consequence of an embryopathy. The malaria attack started 1 day after an operation by the ophthalmologist on account of extant cataracts and within 24 hours death followed.
In the period July 1, 1954 till July 1, 1958 in the children’s ward in Bethesda hospital of 193 children malaria was diagnosed, resp.:

  • 120 times malaria tropica,
  • 62 times malaria tertiana,
  • 11 times malaria quartana.

However in 99 patients malaria infection was also the indication for admission, because of fever convulsion through malaria, (27 times) serious anaemia, persistent vomiting. Dehydration through malaria in fection (6 times) or because the child made the impression of being too ill for policlinical treatment to be justifyable. In the other 94 cases, besides the disease that was the indication for admission (malnutrition, pneumonia, diphtheria, trauma, et al.), also malaria infection was found and treated during the period of admission to the children’s ward. We left the 14 cases, in which a connection with a recent blood transfusion was thought likely, out of the numbers mentioned above. In the children’s ward some dozens of bloodtransfusions are annually given, which we judge necessary during the treatment of children with a serious anaemia, malnutrition, or dehydration. We were conscious of the risk of causing inoculation-malaria and had the donors (mostly parents or other relatives) examined on malaria-plas-modies, before the blood was taken. This precaustion however was evidently not able to prevent these 14 cases of probable inoculation-malaria. They concerned in 9 cases malaria tertiana,
in 4 cases malaria tropica, in 1 case malaria quartana.

The diagnosis inoculation-malaria in those 14 cases was made eleven times 10-19 days after the bloodtransfusion given by pointing out malaria plasmodies in the blood during a fever. In four cases a fever-top preceded some days before, during which the blood was examined as to malaria, but no plasmodies could as yet be demonstrated. In the other three cases malaria plasmodies were found in the blood 3, 26 and 31 days after the blood transfusion.
Blackwater-fever is very seldom met with in this region. During the four-years inquiry period only one blackwater-fever patient was admitted to Bethesda hospital. It was a boy 4 years of age, coming from ketjamatan Prambanan, who was admitted in a very serious condition and who recovered. The therapy consisted in intravenous fluid therapy, bloodtransfusions during the first three days of admission and nivaquine. During the disease we found no malaria plasmodies in the blood of this patient. After the conclusion of this inquiry, in March 1959, another boy, 9 years of age, suffering from blackwater-fever was admitted to Bethesda hospital. This patient was a resident of the city of Jogjakarta; he too recovered.