The occurrence of tuberculosis in Java appeared to exist in every place, where an inquiry into the spread of this disease was made. Very probably this disease was for a long time been endemic among the Indonesian population. The many names which are used by the population for this disease give evidence of it (de Langen, 1919, Paneth, 1928, Djamil, 1929). also the arguments drawn form the Hindu-Javanese history suggest the probability that tuberculosis occurred in java for many centuries and possibly dates from before or from the period in which Hindus came to Java (van Joost, 1951). In the period 1930-1941 many investigations concerning the occurrence of tuberculosis in Java were made and published in the reports of Symposia on Tuberculosis for the years 1939, 1937 and 1939 held in Malang, Semarang and Bandung In Java respectively. The first investigation concerning tuberculosis in childhood in Indonesia is made by de Haas, Te Bek Siang and Injo Beng Liong at Djakarta in the period 1933-1939.
The oldest data about the occurrence of tuberculosis among the population of the D.I. Jogjakarta are from 1904. In the annual reports of Bethesda hospital for the period 1904 till 1936 data about tuberculosis concerning patients living in this region are mentioned. In the period 1904-1910 25 patients suffering from tuberculosis were annually admitted to the hospital. This was 1.7% of all admissions. In the period 1930-1935 every year 220 patients suffering from pulmonary tuberculosis were admitted. This was 2.8% of all admissions. A systematic investigation of the population of this region has never been done either before or after the second world war, so that the frequency of occurrence of tuberculosis among the population is unknown. An exact judgement about the importance of tuberculosis as a cause of illness and death is not yet possible. In 1933 a small tuberculosis-consultation bureau was established in Jogjakarta but examination was done without a specialist for pulmonary diseases and without X-ray. The influence of this bureau remained slight in the pre-war years. In 1951 for the second time a consultation bureau was founded which became the centre for all tuberculosis-fighting activities in this region. Since 1957 also the B.C.G.-vaccination centre has resided in Jogjakarta. By this B.C.G.-vaccination centre a number of investigations was made in the D.I. Jogjakarta. Some of the results are collected in the next table IX-12.
Table IX – 12.
Result of the Mantoux-investigation (Mantoux-test 1/2000) of several population-groups in D.I. Jogjakarta, 1954-1959(according to the data of the B.C.G.-center at Jogjakarta.
In the year 1954 in 13 districts of the city of Jogjakarta an investigation with the mantoux test was made among the inhabitants of these districts. This investigation preceded the inoculation with B.C.G.-vaccin. The Mantoux test was made with a solution of 1/2000. About 20% of the total population of the city were included in this investigation. Because many persons who were examined with the Mantoux test did not return after three days for reading the test, in 45,081 persons the test was finished. Some additional investigations were made in 9,807 pupils of the local secondary schools and in 2,712 officials. In the period 1957 – 1958 also in the kabupaten Bantul and Gunung Kidul an extensive investigation with the Mantoux test was made in 30% and 17% of the population of these kabupatens respectively. In Sleman 1,400 schoolchildren were examined with the Mantoux test. All these data are mentioned in table IX-12.
These investigations were made by the team of the B.C.G.-vaccination centre at Jogjakarta, which is the centre for the whole country. In every person examined 5.T. Units P.P.D. Were inoculated intracutaneously in 0.1 cc. In the left forearm. After 3 times 24 hours the result was examined and the indurations eith a section of 10 mm and more were considered as postitive. The tuberculine used was obtained from the laboratory Alabang at Manilla, only a small part was obtained from the laboratory pasteur at Bandung and gauged with the Phillipine tuberculine. The criterion of the induration of 10 mm and over is also accepted in Burma, Taiwan and Cambodjo according the advice of W.H.O. The number of Mantoux reactions considered as positive is minimal when this criterion is used. The data about the Mantoux-positive persons in the different age groups living in Jogjakarta demonstrate higher percentages in this urban than in the rural population of the kabupatens.
The 3-4 age groups which were distinguished in these investigations were as accurate as possible under the local conditions. When we take the percentage of the Mantoux-positive persons of each age group for the oldest year group of each age group as a basis for the calculation of the infection-rate according to the Method of Heynsius van den Berg (1937), we see that the infection-rate of the population of Gunung Kidul is less than 1%, just as this is the case with the population of Sleman. The infection-rate of the population living in the kabupaten Bantul is about 1%. However we find in the different age groups of the urban populations infection-rates ranging from 5½ – 9½ percent. The higher infection-rate in the city is no reason for surprise. In the last decade only a few new houses have been built in the city while the number of inhabitants has increased rather rapidly. Many houses of the city are therefore very much overcrowded. As a rule a house is used by 2 – 3 families, often also boarders live with these families. In this way one family has only 1-2 small rooms at their disposal. In the town districts the houses are built very near together. If one member of a family suffers from pulmonary tuberculosis, the infection chance for his co-tenant of the house and his neighbours is rather great. In the rural areas, where people live in small dukuhs, where mostly 200 – 500 people live together in one hamket and every family has as a rule its own house surrounded with compounds, the infection chance is smaller. The distance between the dukuhs is as a rule 1-2 KM. A patient suffering from pulmonary tuberculosis is therefore in the rural regions more isolated than in the districts of the city.
The numbers of infectious patients with pulmonary tuberculosis in the city of Jogjakarta can only be estimated with the following data. In the review of the activities of the consultation bureau at Jogjakarta during the period 1951 – 1956 Samallo mentioned that in 3617 persons the diagnosis pulmonary tuberculosis was made. This diagnosis was based on the findings of X-ray examinations and the demonstration of tubercle bacilli in the sputum by microscopical examination.
In 5,024 persons the diagnosis was very probable by the findings of the X-ray examination, but in the routine examination of the sputum tubercle bacilli were not demonstrated. In about 10% of all the 87,126 persons who were examined in the consultation bureau the diagnosis pulmonary tuberculosis was certain or very probable. Out of these 8,641 patients 5,100 lived in the city of Jogjakarta. This concerns persons, who were sufficiently medical-minded to request an examination by the physician. The greater part of these patients had no complaints. In the period 1956-1958 about 1,500 new patients suffering from tuberculosis and living in the city of Jogjakarta were discovered at this bureau. In these patients tubercle bacilli were demonstrated in the sputum. The number of infectious patients suffering from pulmonary tuberculosis living in the city may be estimated at many thousands. A high percentage of Mantoux-positive children in the city can be explained from this. Besides in the city of Jogjakarta also in other cities of the countries high percentages of Mantoux-positive children were demonstrated through Mantoux tests by the teams of the B.C.G.-vaccination centre using the same method. Some of these date are given in table IX-12a.
Table IX – 12a.
Survey of percentage of Mantoux-positive people observed during extensive investigations among the population of several Indonesian towns (1953-1958).
In the cities of Java the figures are higher than the figures of the cities of Sumatera and other islands. The result of the great number of infectious patients suffering from pulmonary tuberculosis can be proved from these high figures of Mantoux-positive children and also from the experience of tuberculosis in childhood gained in the children’s ward at Jogjakarta.
In the period July 1, 1954 till July 1, 1958 , a number of 263 children suffering from tuberculosis were admitted to the two children’s wards mentioned in the other sections of this chapter. All these patients were aged less than 10 and lived in the D.I. Jogjakarta. In 199 out of these 263 patients tuberculosis was also the reason for admission. In the other patients tuberculosis was discovered during the stay in the ward. These children were admitted because of malnutrition, dysenteria, diptheria, bronchiolitis, pneumonia or malaria. Every patient admitted to the children’s ward was as a rule also examined with the Mantoux test 1/1,000 and in a number of cases also with 1/1,000. Mortality among these 263 patients on account of tuberculosis was 62, (of meningitis tuberculosis 34, of miliary tuberculosis 16). In infancy tuberculosis appeared to be no important cause of death because only 2.2% of the infants who died in the children’s wards died of tuberculosis. At pre-school age and school-age this percentage ranged between 4-9% (see table VII-7).
Arranged according to place of residence 65% lived in the city, 20% in Sleman, 13% in Bantul while from the kabupaten Gunung Kidul and Kulon Progo only a few cases were observed, vis. 1 and 4 respectively.
Primary tuberculosis.
The diagnosis primary tuberculosis was made in infants and toddlers aged less than 2 who appeared to have a positive Mantoux test with a solution of 1/1,000 or 1/100 and had never received B.C.G.-vaccination. In toddlers aged 2 and over the diagnosis tuberculosis was made and treatment given when besides the positive Mantoux test symptoms of activity of a tuberculous infection could be demonstrated also such as anorexia, fever, retardation of growth, coughing for many weeks, increased blood sedimentation rate. In children aged less than two we consider it as improbable that a primary infection should already have passed at that age and therefore these children were treated also when the symptoms of activity of a tuberculous infection were not clear. The type of tuberculin used was the same in the two children’s wards.
Table IX – 13.
Survey of the patients, suffering from tuberculosis, who were admitted in two children’s wards at Jogjakarta during the period July 1, 1954 till July 1, 1958, arranged according to age and form of tuberculosis.
The children, aged less than two, who had a positive Mantoux test showed in 74% also alterations in an X-ray photograph or in fluoroscope.
It was not possible to examine all children of the out-patient’s department with the Mantoux test, so we limited this examination to:
- children who had coughed longer than two weeks.
- children living in the same house as known tuberculous patients.
- children living in the same house with persons who had been coughing for a long time.
In this way also 30 children suffering from primary tuberculosis were discovered but not admitted either, because the parents refused to consent to this, or because of lack of place in the ward. These patients are not taken into consideration in this review.
The treatment of the patients suffering from primary tuberculosis was bedrest, well balanced diet, I.N.H. 8 mg per Kg bodyweight daily for 6 months, and streptomycin 40 mg per Kg bodyweight daily for one month, and three times a week for two months. As a rule it was possible to treat these patients for three months in the children’s ward and continue the I.N.H. Treatment after discharge for several months.
Of the patients suffering from primary tuberculosis 8 died. Out of these 8 patients 7 were infants in the first half year of life, while the other child aged 1, suffered also from malnutrition. Four times it was possible to do a liver puncture postmortem while in two of them the pathologist demonstrated tubercles in the liver tissue. In two other patients it was possible to isolate tubercle bacilli from the gastric juice. So that in four out of the 8 patients who died of tuberculosis the causative organism could be demonstrated. The diagnosis primary tuberculosis is in many cases far from easy. As a rule the difficult and doubtful cases were also judged by the specialist for lung diseases.
Miliary tuberculosis
In the same four-year period a number of 24 patients suffering from miliary tuberculosis were admitted to the two children’s wards. This diagnosis was based on clinical manifestations, X-ray examination, Mantoux-test, and findings in the laboratory. Mortality among these patients was high. Sixteen out of these 24 patients died in the children’s ward. Six already within 3 times 24 hours after admission. In 5 patients who died of this disease it was possible to do a liverpuncture postmortem. The pathologist demonstrated in 3 cases acid-fast bacilli in the liver tissue. The inoculation of guinea pigs appeared to be of little significance for the diagnosis tuberculosis. Eleven times gastric juice of different patients was sent to the Central Laboratory for bacteriological examination. Only once was it possible to isolate tubercle bacilli through inoculation of guinea pigs.
The age distribution of the 16 patients, who died of miliary tuberculosis was as follows: 6 infants, aged 2 to 11 months; and 10 toddlers aged 1-4 years respectively 5 toddlers aged 1, 1 aged 2, 2 aged 3 and 2 aged 4.
The treatment of the patients suffering from miliary tuberculosis was the same as that of the patients with primary tuberculosis but bedrest was prolonged to 6-12 months. The treatment after the third month was beside I.N.H. Also P.A.S.
Tuberculous meningitis.
In the same period 50 patients suffering from tuberculous meningitis were admitted to the two children’s wards at Jogjakarta. Because these patients were taken to hospital some weeks after the beginning of the first symptoms, the disease was in an advanced stage. As a rule hemiparesis, doziness, unconsciousness, squinting, or convulsions were the reasons why parents took a child to hospital. These circumstances left few possibilities in many cases for treatment. Thirty-four of these 50 patients died, 19 already within 3 times 24 hours after admission. The age distribution of the patients suffering from tuberculous meningitis, can be seen in table IX-3. The age distribution of the 34 children who died of this disease was as follows: 5 infants aged between 6 and 11 months of life, 13 toddlers aged 1, 8 aged 2, 2 aged 3, 3 aged 4, and one aged 5, 6 and 8 respectively.
Diagnosis was based on clinical manifestations, anamnesis, findings on examining the family, and the findings at the laboratory in the cerebrospinal fluid of the patients. It was possible to examine at the laboratory the C.S. Fluid with the Pandy- and Nonne-test, the number of cells per mm3, the percentage of glucose, protein and NaCl. Only once was it possible to isolate tubercle bacilli from the C.S. Fluid by inoculating a guinee pig with this fluid. In 9 patients who died of tuberculous meningitis it was possible to take a little liver tissue postmortem by puncture. In three of them the pathologist demonstrated tubercles in the liver tissue.
In the greater part of the patients suffering from tuberculous meningitis it was possible to find the most probable source of infection. In these cases one of the parents, grandparents, neighbours or servants appeared to have been treated because of tuberculosis at the Consultation bureau in Jogjakarta.
In three patients beside the tuberculous meningitis miliary tubercuosis was also found. Only one of these three patients survived.
The treatment of the patients suffering from tuberculous meningitis was streptomycine 40-50 mg per kg bodyweight daily for one month, and three times weekly for 5 months, I.N.H. 8-10 mg per kg bodyweight daily for one year and P.A.S. Was given after stopping the streptomycine treatment, so that the child had after 6 months of streptomycine another 6 months of P.A.S. treatment.
This at least was our intention for treatment. As a rule it appeared to be very difficult to keep the child in hospital for longer than 6-8 months, because the parents did not allow a longer stay.
Tuberculosis of bones and joints in childhood.
This manifestation of tuberculosis occurred at a comparatively higher age than the average age of patients suffering from primary tuberculosis, miliary tuberculosis and tuberculous meningitis. The average age of the patients with bone and joint tuberculosis was 6 years. The youngest patients suffering from spondylitis and tuberculous pleuritis was aged 1½. As a rule patients with tuberculosis of bones and joints were admitted to the surgical department and in the course of the period of treatment removed to the Sanatorium at Pakem, which is situated in the neighbourhood of Jogjakarta at a height of 700 m. above sealevel on the slope of the volcano Merapi. The total number of these patients in the period July 1, 1954 till July 1, 1958 was 28. In 11 patients the tuberculosus infection was manifest in the hipjoint and in 16 cases this infection occurred in the vertebral column. Only one patient died at the age of 4½ year. She suffered from tuberculosis of the right hipjoint and of the trochanter major of the right femur. After two years in the children’s ward she died in cachexia.
Pulmonary tuberculosis.
Pulmonary tuberculosis was the cause of death in two children aged resp. 7 and 8.
According to the statement of the chief of the Veterinary institute bovin tuberculosis does not occur in the D.I. Jogjakarta, so that the tuberculosis in this area is caused by the mycobacterium tuberculosis of the human type. The occurrence of tuberculosis in childhood is therefore closely connected with tuberculosis among the adult part of the population.
The way of fighting tuberculosis as it happened in European countries is impossible in Java. In European countries the mortality of tuberculosis decreased in the first half of the 20th century, when the circumstances of life improved considerable. The wages, housing, and feeding improved for a great part of the population in this region of the world. Even before systematic fighting of tuberculosis occurred on a large scale the morbidity and mortality of tuberculosis already decreased in these countries, and it is possible that the influence of improved feeding and housing should have been the most important unspectific factors which diminished the suffering from tuberculosis in that period.
The rising standard of living made it possible to decrease tuberculosis by means of a number of special measure among the population.
It was possible for nearly every patient suffering from tuberculosis to be treated according to the insight gained during a long period of experience. In the case of many patients it was possible to combine a special treatment with isolating either in a sanatorium or in the patient’s own house. The number of possible sources of infections diminished in this way, and by means of a systematic tracing of patients among the whole population was traced carefully.
Besides the number of sources of infection among the population also the sources of infection among the cattle were traced and made harmless for the population.
Milk which was in former days a source of infection is nowadays no longer of great importance in the spread of this disease.
Persons who were in special danger, e.g. Nurses, member of the families of patients suffering from tuberculosis, medical students, were protected by inoculation with B.C.G. Improving social provisions diminished many of the financial cares of the patients who had to be treated for rather a long period.
The circumstance that the society was aware of the danger of infection by patients caused these patients to be no longer tolerated but shunned. For the patients this was often a stimulus to request treatment. As a rule the insight of the patients in the nature of this disease and the readiness to follow the rules of the sanatorium were sufficient, so that the greater part of the patients could be treated satisfactorily.
The circumstances prevailing in Java nowadays differ completely from the above circumstances in European countries. The low standard of living for the greater part of the population means that the daily diet is qualitatively not well balanced and in many cases quantitatively also insufficient. Underfed people living in overcrowded house are in large parts of many towns a “normal” phenomenon. Isolating a patient suffering from tuberculosis in his own, dark, small house, which is used by two or three other families too, is impossible.
Lack of insight in the nature of the disease makes Javanese society very tolerant to persons who are coughing for a long period. Even the death of a child of tuberculosis caused by an infection from the grandmother, who lived in the same house is for the parents no reason to take some measures for protecting the other children of the family. To spare the feelings of the grandmother the father of the child omitted to discuss the problem of danger for the other children with the grandmother and did not try to change the circumstances. The definition of “asocial tuberculosis-patient” as existing in Europe, is of no use to get an insight in the conditions of tuberculosis in Java. Javanese society fully accepts and tolerates patients who are suffering from open tuberculosis among them. The patients themselves mostly request medical help when the disease is in an advanced stage. When emaciation, severe dyspnea and sometimes hemoptoe are present, the patients are taken to hospital. In many cases then is no chance of treatment left any more. After admission to hospital it is only in a few cases possible to keep a patient long enough for a complete treatment. Mostly when the patient feels better he likes to go home to stay in the milieu of his own family and/or it is not longer possible to let his family go without the money he can earn outside the hospital.
Treatment in and admission to a sanatorium are possible in Java for only a limited number of patients, who are able to contribute substantially to the costs. In the D.I. Jogjakarta about 200 sanatoriumbeds are available.
In the circumstances as they are present in Java there is little hope that a systematic fighting of tuberculosis can have great influence on the morbidity and mortality of this disease. The hygienic, social and economic conditions are such that a rising of the standard of living is the only hope that the mortality of this disease will diminish in future. The first treatment of under nourished patients suffering from tuberculosis will be to supply sufficient well balanced food for them and at present this is lacking.
Notwithstanding this fact the method of fighting this disease in Jogjakarta is fully concentrated on specific measures.
Since 1951 the campaign of fighting tuberculosis is based upon:
- B.C.G. Inoculation.
- Ambulant treatment of every patient suffering from pulmonary tuberculosis
who requests this treatment.
The B.c.g. Inoculation, which already happened in a large part of the D.I. Jogjakarta, may be of importance, but there is no reason to expect a great influence from it under the local circumstances as they are in Java and India (Wallgren, 1957).
The ambulant treatment of a great number of patients suffering from open tuberculosis is a more serious matter. It means a diversion from directing the activities in fighting this disease via the indirect way, i.e. An improving of the standard of living in first instance. It means that all the attention is concentrated on this precarious way of influencing the spread of tuberculosis in this part of Java.
A number of questions arise before this way of fighting tuberculosis can be evaluated.
- Is it possible to treat patients suffering from tuberculosis adaequately without the conditions of bodily and mental tranquility in a suitable milieu, and of a well balanced diet, which are according to all experiences in the past of such great significance? (Bronkhorst, Nauta, 1951, Huet, 1952).
- Is the effect of the streptomycin, I.N.H., and P.A.S. on the course of tuberculosis such that the factor of resistance of the body against this disease became of less importance, making special measures are less necessary?
- Is the result of the ambulant treatment of t.b.-patients as it has been given for several years in Jogjakarta such that this justifies the continuance of this treatment-method?
- After how many months do the organisms, Mycobacterium tuberculosis, become resistant to the effect of the anti-tuberculosis drugs?
- Was this period long enough to cure the patients?
In the annals of the magazine: Berita Tuberculosis Indonesiensis, which has been edited since 1954 we have looked for an answer to these five questions, but in all the articles published none was answered.
According to the experience gained in other countries the value of the anti-tuberculosis drugs available at present was limited by the developing of drugfastness of the causative organisms after several months of treatment with these drugs. When we see the results in the first five years of fighting tuberculosis in Jogjakarta (1951-1956) published by Samallo, we find that the percentage of the 3,612 patients suffering from tuberculosis in whose sputum the Mycobacterium was demonstrated only 1,331 i.e. 36% had negative sputum. However the duration of this treatment and the number of cultures during and after treatment is not mentioned. From these figures it appeared that 2,286 patients had a great chance to develop drugfastness of the causative organisms by this treatment. For the epidemiology this is of great importance. In this period never a test of the drugfastness of Mycobacterium tuberculosis in these patients was made, so that exact figures are lacking. For the future we may expect that the continuance of ambulant treatment on a large scale will be a cause of many children being infected with drugfast organisms and that the usefulness of the available drugs will diminish rapidly in the course of one to two generations. The next generation will very probable experience that the enemy has been underestimated and fought with arms, inadequate to this combat. It is inconceivable that this disease which maintains itself so well in this social milleu will be forced back by the type of treatment mentioned above.
The consequences of this ambulant treatment for young children we already observe in the children’s ward. With the following case-history we should like to illustrate this matter.
SETIJOWATI, girl aged 4. This girl was admitted on February 8, 1957. For 4 months she had coughed and had had a fever now and then. In the out-patients-clinic the Mantoux-test was made and in a solution 1/100 it was positive. The X-ray examination demonstrated that in the left lung alterations were present and the lymphnodes of both hili were enlarged. She made no sick impression, bodyweight 9.2 Kg. The blood-sedimentation rate was 80/95 mm after one and two hours respectively on February 11. she had a good appetite. In the gastric juice the acid-fast organisms could be demonstrated in a smear stained according to Ziehl-Neelsen. The inoculation of the guinee pig appeared also to be positive. An examination of the drugfastness was not yet possible in Jogjakarta at the time. Because the child was in a good general condition the parents agreed to her being removed to Pakem Sanatorium on February 20. there she was treated with bedrest, well balanced diet, streptomycin 450 mg daily and I.N.H. 75 mg daily. This treatment has already been given for 24 days, when her behaviour changed a little, appetite diminished and she became less active.
For further examination she returned to the children’s ward on march 14, 1957. A complication of tuberculous meningitis was feared, and examination of the cerebral spinal fluid confirmed this supposition. The treatment in the course of which this complication had developed was continued, because no other possibilities were left. The disease appeared to be progressive and 32 days after the first symptom of tuberculous meningitis she died on April 14, 1957. the course of this disease made it very probable that the girl suffered from tuberculosis caused by a drugfast organism. The development of meningitis during treatment strengthens this supposition. In the anamnesis we found the following facts. The child lived with her parents and her aunt. This aunt had suffered from coughing for a long perriod and was treated at the consultation bureau at Jogjakarta because of tuberculosis with streptomycin, P.A.S. and I.N.H. In the last 1½ years she had got more than 200 grams of streptomycin besides the I.N.H. And P.A.S.treatment.
Examination of the parents, demonstrated that they were healthy. Of the four children of the parents the first and second has died after 50 days, and 1 day respectively. Setijowati was the third child. The fourth child, a girl of 7 months was not taken to hospital for examination. The most probable source of infection for Setijowati was this aunt, living in the same house and who had very probable drugfast bacilli in the sputum. 1½ months before this girl was admitted this aunt was removed to Somarang, where she got an hemoptoe.
This case-history we consider as a consequence of the ambulant treatment of tuberculosis patients as it happens in Jogjakarta and in future this type of drugfast tuberculosis will be a warning that it is necessary to revert attention to the five questions mentioned above.