In the survey of causes of death in childhood as it is given in table VII-7 only 4 cases are mentioned of poliomyelitis. These patients aged 2 months, 1.1, and 5 years respectively died of bulbar paralysis, caused by poliomyelitis.
During the period July 1, 1954 – July 1, 1958, 256 patients, viz. 137 boys and 119 girls, suffering from paralysis by poliomyelitis were observed in the out-patients department of Gadjah Mada University and of Bethesda hospital. These 256 patients were living in the D.I. Jogjakarta and were aged less than 10. Out of these patients only 4 died. The mortality was therefore 1.6% under that of the patients we observed and who were infected between January 1, 1954 and July 1, 1958. The date of infection of these patients we got from the anamnesis obtained from the parents. Many parents told that besides their own child other children living in the parents told that besides their own child other children living in the same desa suffered from paralysis after fever at nearly the same time, so that the patients observed are only a part of the real number of poliomyelitis patients during this period in this region.
Poliomyelitis was the only infectious disease of which we twice observed an epidemic rise in this period. The first rise was in the months May till September 1954 (91 cases) and the second time this happened in the period March-June 1957 (41 cases). The epidemic rises happened in the dry monsoon, the epidemic during 1954 is described by Perabo and Ismangoen in the Journal of the Indonesian Medical Association.
It appeared from the data about the 256 patients we observed that poliomyelitis is exclusively a children’s disease in the D.I. Jogjakarta. The oldest patient was 8 year of age. Also according to the information about the ages of poliomyelitis patients observed by other colleagues working in this area it is only seen in childhood. The age distribution of these patients is given in figure 23a. Eighty-six per cent. Of these patients were in the first three years of life, mostly in the age-group 6-24 months of life. This age distribution is not exceptional in an Asiatic country. Data about the age distribution of patients suffering from poliomyelitis in India (Bombay, 1949), Ceylon(1948-1949), Japan (1946), and Palestine (1950) mentioned this same type of age distribution. The data concerning India were mentioned by Pandit and Ramalingaswami (1955).
Out of 396 patients suffering from this disease and treated in Safdarjung hospital in New Delhi during 1949 till 1954, 90% was aged 0-5.
Fig. 23A
Age distribution of 256 paralytic poliomyelitis patients, Jogjakarta, 1954-1958.
This pattern of age distribution was also found in the analysis of the patients during the poliomyelitis epidemic in Bombay in 1949 (253 cases), 1952 (168 cases), 1954 (259 cases) and during the epidemic in Dohad in 1952 (75 cases). De Silva mentioned about the age distribution of poliomyelitis patients in Ceylon that 75% of them were aged less than 3 in the period 1948-1949.
The victims of the small epidemics which have occurred in Japan since 1921 were in 70% of these cases children aged less than 3 and in 90% children aged less than 5 (Paul, 1947).
In Palestine the age distribution of the more than 400 patients treated for poliomyelitis in the Government Hospital in Haifa was such that 93%was aged less than 6 (Frank, 1951).
The age distribution of the poliomyelitis patients in the D.I. Jogjakarta, which is thus of the same type as elsewhere in Asia demonstrates that the adult population is highly immune to poliomyelitis virus. Also in the first six months of life paralysis due to poliomyelitis is seldom observed and it seems that in this period the immunity which the child received from its mother by transmission through the placenta gradually disappears.
Out of the 55 patients suffering from this disease in the first year of life only 5 were aged less than 6 months, viz. 2.3½ , 4.5 and 5 months. The youngest patient died of bulbar paralysis. Before the ninth year of life nearly everybody seems to acquiry immunity to this disease in this area.
A number of immunological surveys which were made in Asian countries, Korea, Okinawa, Japan and China (Sabin, 1955) indicated that a rapid rise in poliomyelitis antibodies occurred after the first year of life. Also in Egypt and French Morocco surveys made this clear. Also a relation between unsatisfactory sanitary conditions and a great chance of infection with poliomyelitis virus in early childhood was made probable by these immunological surveys.
The factor of:
a great number of children family,
the way of living closely together in small villages and town districts,
the intensive contact between playing, maked, young children favour the increase of infection chances by this disease.
Poliomyelitis, endemic in this region, was regularly observed. Besides the epidemic rise in the periods mentioned above, nearly every month patients suffering from paralysis by poliomyelitis were taken to the out patients department. A survey of the cases observed per month during the period July 1, 1954 till January 1, 1959 arranged according to the date of the first symptoms of the disease is given in table IX-21.
Table IX – 21
Survey of the poliomyelitis patients observed during July 1, 1954 till Jan. 1, 1959 arranged according
to the date of infection.
Arranged according to the place of residence it appeared that 50% of them lived in the city of Jogjakarts, 28% in the kabupaten Sleman, 15% in the kabupaten Bantul, while the other children lived in Gunung Kidul and Kulon Progo. This distribution agress with the distribution of all the patients admitted in the children’s wards. The places of residence in the city and in the different kabupatens were spread all over the area.
Diagnosis was difficult only in rare cases. As a rule the patients were taken to hospital after the paralysis became manifest. Asymetrical paralysis, absence of deep tendon reflexes in the involved areas, hypotonicity of the paralysed limb, and anamnesis are mostly sufficient for diagnosis.
Out of the 256 patients observed 209 suffered from paralysis of the lower extremities. It is probable that mothers were more deeply impressed by paralysed legs than by paralysed arms or abdominal muscles. In the anamnesis of patients with paralysed legs mothers told 26 times that the child got an injection in the same leg because of fever some days before the lag was paralysed.
In this region it is customary for most patients not to be satisfied with a treatment by a physian or male nurses, who practise independently if the patients don’t receive an injection. An injection became the brand of a “complete” treatment. If the doctor withholds an injection it is requested by the patient. This was caused by the startling success of the Neo-Salversan therapy of Yaws in the pre-war period. This custom lead to the circumstance that many patients receive injections e.g. Because of fever, diarrhoea, coughing and so on. Also a number of poliomyelitis patients received in the preparalytic phase an injection (Quinine-antipyrine or penicillin) because of fever. We suppose that these injections favoured the development of paralysis in the extremities where the injections were given. This relation between injection and paralysis is described by several authors (Mc Closkey, Bradford Hill, Verjaal, Anderson and others).
The virus types which are the causative agents of the paralysis of the patients in the D.I. Jogjakarta are unknown. Identification of poliomyelitis virus types occurring in Indonesia has not yet been done. Perabo used the opportunity to send cerebrospinal fluid of one patient suffering from poliomyelitisto the laboratory of J.F.Ender in Boston. In this C.S. Fluid an unusual high titer against type I (Brunhilde) was demonstrated by Ender.