In infancy and early childhood typhoid fever did not appear to be an important cause of death or of illness in Jogjakarta. Especially young adults suffer from typhoid fever. In the period July 1, 1954 till July 1, 1958 we observed only two toddlers, boys aged 1½ and 4 respectively, who suffered from typhoid fever in Bethesda children’s ward. In this same period 239 patients suffering from typhoid fever were admitted to Bethesda Hospital at Jogjakarta. A yearly average of 60 patients admitted with typhoid fever in this hospital only means that this disease is not a rare thing in this region. The age distribution of these 141 male and 98 female patients was as mentioned in table IX-10.
Table IX – 10.
Age distribution of 239 patients suffering from typhoid fever, who were admitted in Bethesda hospital, Jogjakarta in the period July 1, 1954 till July 1, 1958.
It appears that this disease is most frequent in the age-group 15-19 years. In the age-group 10-30 years 66% of these 239 patients were registered, while only 14% appeared to be aged less than 10. Typhoid fever is far more frequently observed in the ward for internal diseases than in the children’s ward. Diagnosis was based on the clinical manifestations, anamnesis, and the result of laboratory tests. Bacteriological examination of blood, feces and urine of typhoid fever patients is possible in the Central Laboratory of the Civil Health Service in Jogjakarta. In 89 cases it was possible to isolate Salmonella typhosa from the blood, taken just after admission or just after the beginning of a relapse, In 40 cases the clinical diagnosis was confirmed by the result of serological tests. In these cases the Widal test was positive in a titer 1/800 and higher. In another 15 cases the Widal test was positive in a titer of 1/400. As a rule patients suffering from typhoid fever were admitted in the second or third week after the beginning of the disease. This circumstance hampers the bacteriological examination as, especially in the beginning of the course of the disease, it is easier to isolate the Salmonella typhosa from the blood of patients than afterwards. The Widal test is made with a mixture of 0- and H-antigens, so that the highest titer of agglutinines against one of these antigens is measured. The diagnosis in the other 94 cases was based on the clinical manifestations after excluding the most important differential diagnosis which are of importance in these regions: viz. malaria tropica, purulent meningitis, pneumonia and miliary tuberculosis. Paratyphoid A-infections are rather rare in this region. In the four-year period, mentioned above, in which 89 times Salmonella typhosa could be isolated from the blood of suspected patients, Salmonella paratyphi A was found only twice.
Among the 239 patients were 33 children aged less than 10. In the period May 1, 1955 till July 1, 1958 13 children suffering from typhoid fever were admitted to the University children’s ward. The age distribution of the 46 children with typhoid fever is shown in table IX-11.
Table IX – 11.
Age distribution of 46 children suffering from typhoid fever and admitted in two children’s wards at Jogjakarta.
It appears that this disease is most frequent in the age-group 15-19 years. In the age-group 10-30 years 66% of these 239 patients were registered, while only 14% appeared to be aged less than 10. Typhoid fever is far more frequently observed in the ward for internal diseases than in the children’s ward. Diagnosis was based on the clinical manifestations, anamnesis, and the result of laboratory tests. Bacteriological examination of blood, feces and urine of typhoid fever patients is possible in the Central Laboratory of the Civil Health Service in Jogjakarta. In 89 cases it was possible to isolate Salmonella typhosa from the blood, taken just after admission or just after the beginning of a relapse, In 40 cases the clinical diagnosis was confirmed by the result of serological tests. In these cases the Widal test was positive in a titer 1/800 and higher. In another 15 cases the Widal test was positive in a titer of 1/400. As a rule patients suffering from typhoid fever were admitted in the second or third week after the beginning of the disease. This circumstance hampers the bacteriological examination as, especially in the beginning of the course of the disease, it is easier to isolate the Salmonella typhosa from the blood of patients than afterwards. The Widal test is made with a mixture of 0- and H-antigens, so that the highest titer of agglutinines against one of these antigens is measured. The diagnosis in the other 94 cases was based on the clinical manifestations after excluding the most important differential diagnosis which are of importance in these regions: viz. malaria tropica, purulent meningitis, pneumonia and miliary tuberculosis. Paratyphoid A-infections are rather rare in this region. In the four-year period, mentioned above, in which 89 times Salmonella typhosa could be isolated from the blood of suspected patients, Salmonella paratyphi A was found only twice.
Among the 239 patients were 33 children aged less than 10. In the period May 1, 1955 till July 1, 1958 13 children suffering from typhoid fever were admitted to the University children’s ward. The age distribution of the 46 children with typhoid fever is shown in table IX-11. It appears that the disease becomes less rare at school-age
Table IX - 11.
Age distribution of 46 children suffering from typhoid fever and admitted in two children’s wards at Jogjakarta.
Mortality among these 45 patients was 15% this high mortality is due to the fact that the patients stayed at home for some weeks after the beginning of the disease before admission was requested. Then patients are often in a bad general condition.
Six out of the seven patients who died, did so within 2 x 24 hours after admission. One died after perforation of the intestine.
The patients suffering from typhoid fever were treated with bedrest, chloromycetin, smooth diet and adequate nursing. Sometimes in travenous fluid therapy was necessary. The mortality among the patients aged 10 and over was during the period July 1, 1954 till July 1, 1958 19%, viz. 38 out of a number of 206 patients.
About the epidemiology of typhoid fever in the D.I. Jogjakarta only little is known. In 1936 Maasland wrote that typhoid fever had occurred for years in this region as a very diffuse endemic disease which only now and then showed epidemic rises. This description also tallies with the data which are available about the present occurrence of typhoid fever in this region. During the period 1925-1935 the annual number of typhoid fever patients who were admitted to Bethesda Hospital ranged between 25 and 57. The capacity of the hospital was 350 at the time while it is somewhat greater now. In all parts of the D.I. Jogjakarta typhoid fever occurs. The place of residence of the 239 patients who were admitted because of this disease in the period July 1954 till July 1958 was as follows. The city: 79 (33%); Kabupaten sleman: 126 (53%); Kabupaten Bantul: 23 (10%); Kabupaten Kulon Progo: 8 (3%); Kabupaten Gunung Kidul 3(1%). Although the number of patients living in the Kabupaten Kabupaten Kulon Progo and Gunung Kidul is very small in this group according to the information of the colleagues in charge of the hospitals in Wates and Wonosari, typhoid patients are regularly observed also in these hospitals. Some small epidemics of typhoid fever occurred in 1957 in a boardingschool at Jogjakarta (13 cases), in 1958 in Karangmodjo, Gunung Kidul (30 cases) and in Sept. 1959 in Semin, Gunung Kidul (44 cases) among the users of the same well (communication H.J. Nielen).
Investigations concerning the epidemiology of typhoid fever in Indonesia were only sporadically made. In 1940 Schaeffer published the data of his investigation into the occurrence of Salmonella typhosa in the sewerage of the city of Jogjakarta, which appeared to be severely infected. Schaeffer could isolate 83 Salmonella organisms per cc sewage.
His investigation made it very probable that the Salmonella strains entered the sewage together with the feces and urine of the persons who carried these strains. Another investigation of Schaeffer in Bandung (1941) demonstrated that the sewerage in this city, too, was severely infected with Salmonella typhosa.
The result of the tests of sewage specimens taken from different places and at different hours demonstrated e.g. That in the early morning at 5 o’clock only 8 Salmonella organisms could be isolated per 10 cc sewage, but several hours later when feces in important quantities had entered the sewerage 330 Salmonellas could be isolated per cc sewage. This meant that the number of Salmonella organisms multiplied 400 times within a few hours. This is only possible with a great number of Salmonella-carriers among the people who used the water closets of the houses connected with the sewerage of the city. In Jogjakarta are about 3,600 private houses and 550 city-maintained public toilets connected with the sewerage.
When we suppose that 25 persons on an average use one toilet, this would mean that only 100,000 people out of the city-population of 270,000 dispose of their stools via the sewerage. The removal of the feces of the other part of the population inside and outside the town is not satisfactory. The opportunity for “fecal contact” is abundant. The lack of latrines in good conditions, which are adequately used offers opportunity for infection in the neighbourhood of Salmonella carriers. The open gutters along the streets of the city are used by children and adults as a lavatory, but the street vendor cleans his drinking glasses and dishes there, while the betjakdriver cleans his transport bicycle with their water.
In regions where small rivers and brooks are present these are used as drinking-places and lavatories, as washing- and bathing-places. In the idea of the population of causes of diseases malevolent spirits have a dominant place. Therefore people cannot be induced to separate the source of drinking water from the lavatory. If the producer of diseases is supposed to live in an invisible world there is no reason to make senseless distinctions between drinking water and infected surface water. These circumstances favour very probably the spread of Salmonella infections, Shigella-infections, amebiasis and ancylostomiasis.
The most recent investigation into the epidemiology of typhoid fever in Indonesia was done in the period 1937-1939 in Djakarta by Dinger and co-workers. In the Tanah Tinggi district with 21,780 inhabitants a detailed investigation into the epidemiology was carried out.
- This investigation included an examination of 1952 unselected persons of all age-groups to ascertain the number of persons who were Salmonella carriers. The stools were tested with Endo-medium and with this medium it appeared that only one person carried Salmonella paratyphi A in the stools.
- In the two-year period of this investigation it was possible to diagnose typhoid fever and paratyphoid in 21 and 15 persons. In every patient who was suspected of suffering from typhoid, severe or ambulant, a detailed examination was carried out.
- The youngest patient suffering from this disease was a child two years of age. The frequency of typhoid fever was 6 cases per 10,000 inhabitants per year.
- Of all deceased persons in the testdistrict a specimen of the stools was examined and in this way the diagnosis could 3 times be made by isolation Salmonella typhosa. In this period 340 persons died in this district of Djakarta.
- In the examination of 710 persons who had been in contact with typhoid patients or typhoid carriers, or with patients suspected to suffer from typhoid fever, it was possible to isolate Salmonella typhosa in three cases. The frequency of positive stools was higher among ghe contact persons than among the unselected persons.
The results of this investigation of Dinger and co-workers did not indicate a great number of Salmonella carriers. There appeared to exist a contrast between the degree of contamination of the surface water and sewage in Djakarta and the small number of carriers found in this investigation. The sewage was tested with the Wilson-Blair medium and appeared to be severely infected. The investigators did not succeed in finding a great number of mild typhoid cases in spite of the intensive search for this type of patient.
In an analysis of 2,270 cases of typhoid fever in Djakarta during September 1933 till February 1938 there occurred nowhere an accumulation of cases. As a rule there were sporadic cases and only some times a connection of place or time existed between a few cases. In only 18 out of the 2,270 cases was there an indication of the occurrence of a family infection.
From the data resulting from this investigation Dinger and co-workers concluded that the spread of typhoid fever could not be fully explained from direct infections by Salmonella carriers, mild cases or typhoid patients. Also the immunity against this disease which existed among the population of this district could not be explained from the results of this investigation and from inoculation.
Dinger posited a new explanation by supposing that a less virulent source of infection of great capacity caused by avirulent Salmonella strains immunized the population. He supposed that the surface water is this source of avirulent Salmonellas by which the population is contaminated during drinking. Bathing and defecating. In this way the population obtains immunity. This picture of the epidemiology of typhoid fever which differs so much from the knowledge about this subject gained in western countries did not remain without contradiction (C.P. MOM, 1940).
It was remarked that the Endo-medium was not the most suitable medium for tracing Salmonella strains, and that this could explain the small number of Salmonella-carriers found in this investigation. Willson Blair medium was considered more suitable. The small number of Salmonella-carriers found was not in great contrast with the data about the severe contamination of the surface water of the city as Mom could explain from data of investigations elsewhere in Java.
The idea of Dinger that Salmonella multiplied somewhere outside the human body e.g. In the surface water of the city of Djakarta was contradicted because Schaeffer demonstrated by an investigation near Jogjakarta that Salmonella typhosa rapidly disappears in the natural milieu of fishponds so that the multiplying of these organisms in spite of biological selfpurification seems very improbable.
The supposed cross resistence between the Salmonella typhosa and the hypothetic micro-organism, which could explain a lot, was but never proved.
The investigation into the epidemiology of typhoid fever in Indonesia was interrupted by the outbreak of the war in the Pacific in 1942 at a moment when many questions about this subject were still unanswered.
Why were contact infections so rarely demonstrated?
How does immunity against this disease develop while the disease appears to be sporadically endemic?
Why is the age-group of infants and toddlers so free from this disease, while the possibilities of infection seem ubiquitary?