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IMPORTANT INFECTIONS IN INDONESIA

Sn Oemijati*

ABSTRACT

At least 13 species of intestinal and 4 species of blood and tissue nematodes have been reported infecting man in Indonesia. Five species of intestinal nematodes are very common and highly prevalent, especially in the rural areas and slums of the big cities. Those species are , , , and Oxyuris vermicularis, while Strongyloides stercoralis is disappearing. The prevalence of the soil transmitted helminths differs from place to place, depending on many factors such as the type of soil, human behaviour etc. Three species of lymph dwelling filarial worms are known to be endemic. the urban is low endemic in Jakarta and a few other cities along the north coast of Java, with Culex incriminated as vector, high endemicity is found in Irian Jaya, where Anopheline mosquitoes act as vectors. malayi is widely distributed and is still highly endemic in many areas. The zoonotic type is mainly endemic in swampy areas, and has many species of Mansonia mosquitoes as vectors. B.timori so far has been found only in the south eastern part of the archipelago and has as vector. Human infections with parasites have been diagnosed properly only when adult stages were found either in autopsies or removed tissues. Cases of infections with A. caninum, A.braziliense, A.ceylanicwn, colubrifotmis, T.axei and Oesophagostomwn apiostomum have been desribed from autopsies, while infections with spiningerum have been reported from removed tissues. Infections with the larval stages such as VLM, eosinophylic meningitis, occult and other could only be suspected, since the diagnosis was extremely difficult and based on the finding and identification of the parasite. Many cases of creeping eruption which might be caused by the larval stages ofA.caninwnandA.braziliense and Strongyloides stercoralis were diagnosed only clinically. Also diagnosed clinically were occult filariasis which was caused by animal filarial worms, and eosinophylic meningitis caused by Angiostrongylus cantonensis. While and T.cati are prevalent in dogs and cats, in marine fish, no cases of Visceral larva migrains and anisakiasis have been reported in man in Indonesia.

INTRODUCTION man in Indonesia, but only 8 species are pre- valent, widely distributed and cause public In Indonesia, parasitic infections in health problems. Other Nematodes, espe- general are decreasing. However, parasitic cially the non human parasites, may infect infections are still important, especially in man, and cause clinical symptoms, which are rural areas and slums of the big cities. At least sometimes difficult to diagnose, and there- 18 Nematodes have been reported infecting fore not easy to determine the treatment. Be-

* Department of Parasitology, Faculty of Medicine University of Indonesia

Bul. Penelit. Kesehat. 17 (2) 1989 parasites may give different symptoms than helminths were found in the provinces of in the natural host. Moreover, the para- West Java, Yogyakarta, Bali, West Nusa sites themselves, as erratic parasites are hid- Tenggara and South Sulawesi. In 1985, the den in unusual tissues and difficult to be CDC of the Department of Health reported found with the usual technics. overall lower figures, which may be due to the control programmes. Another possibility is Soil transmitted helminths that the data from the Department of health include the whole population, while The most prevalent are the soil trans- Margono's data were results from certain mitted helminths, consisting of Ascaris groups. lumbricoides, Trichuris trichiura, Nector The clinical symptoms of these infections are americanus and Ancylostoma duodenale. usually not severe, but very often disturbing, These parasites are widely distributed and and when calculated in terms of loss of work- may be found in all stool surveys. Before the ing hours because of weakness, , ab- implementation of the control programme, dominal pain and diarrhoea. The economic very high prevalences are common. In many loss caused by these infections may be con- areas, one species may be predominant, but in siderable. Moreover the clinical symptoms other areas high prevalences of all soil trans- are usually not typical and not easy to diag- mitted helminths may be found, while in areas nose. More severe are the unusual symptoms with good sanitary conditions, mostly involv- of complications of soil transmitted helmin- ing the higher socio economic group, low thic infections. Halimun et a15 reported 40 prevalences are common. Ascaris lumbri- cases of complications of Ascaris infection as coides may be found in almost 100% of the intestinal obstruction and acute appendicities, inhabitants of certain areas. Especially high which had occurred in the years 1973-1975. prevalences have been reported in children. infections may cause severe In a slum area in Jakarta, follow up studies of with heart failure as result, while babies born in that area, showed that 100% of Trichuris infection may cause severe anemia the children have been infected with and malnutrition due to dysentery syndrome. A.lumbricoides, when they have reached their Clinical symptoms caused by the larval stages second year of life lv2.In Kresek, West Java, are even more difficult to diagnose. Loeffler's Clarke et a1 (1973) reported A. lumbricoides syndrome caused by the larvae of Ascaris has in 90%, T. nichiura in 91% and hook worm only been suspected and never confirmed in infection in 67% of the stools examined. In Indonesia. The same happens with ground KalirnantaqMasbar and Purnomo reported an itch caused by the larvae of . In- infection of A. lumbricoides in 80%, hook- fections with the non human soil transmitted worm infection in 82% and Trichuris helminths are difficult to confirm, because of nichiura in 78% in a stool surveys, Margono the unusual situation. Toxocara canis and T. made a summary on the results of stool sur- cati are revalent in dogs and cats in In- veys, showed high prevalences in all provin- donesia6'? , but caused ces surveyed except East Nusa Tenggara with by the larvae have never been diagnosed. only 10% A. lumbricoides, 35% T. trichiura and 1% . High prevalen- Some of the soil transmitted helminths ces of all the 3 species of soil transmitted have been decreasing very much. Stron-

Bul. Penelit. Kesehat. 17 (2) 1989 gyloides stercoralis, which Sri Oemijati8 in W.bancroj?i has a wide distribution and is 1956 found 9.4% positives among hospital highly endemic in Irian Jaya. Many species of patients and 16.3% in autopsies, is now rarely mosquitoes have been incriminated as vector. found in surveys, and also in autopsies. Lie As An. farauti, An. subpictus, An. punc- Kian Joe in 1947~found in autopsies in Jakar- tulatus, Ae. Kochi and paCx. bitaeniorrhyn- ta, 47 % positive with Trichostrongylus chus been described as vectors14. colubroformis and T.axei. These worms are Brugia mlayi is strictly rural in occur- now also very rarely found. Moreover these rence, andmay be found in swam y areas 3 species are very small worms, and need and rice fields. The mopbylic type1! which special technics to diagnose. formerly was described as the subperiodic Many species of animal nematodes have type, recently showed that the periodicity is been discovered and identified because of the not strictly subperiodic, but may also show no findings of these worms in autopsies and periodicity at al. This type which may infect clinical cases. , A. , is mostly found in swampy areas and braziliense, A. ceylanicum and Acantho- has as vectors many species of Mansonia cephala have been discovered in autosies1° mosquitoes. while Gnathostom spinigerum have been The anthropophylic type, formerly described 11,12 discovered in clinical cases . as the periodic type has a more restricted distribution then the zoophylic type. This Filariasis para-site is mostly found in rice field areas and has as vector mostly An. barbirosnis. Filariasis still constitutes a major health is a parasite which has problem in Indonesia. The infection is widely been described as a new species16 has been distributed, but the prevalences and inten- found only in the south eastern part of the sities of the infection differ from place to Archipelago, in the Provinces of Nusa Teng- place. In areas where the Filariasis Control gara Timur, consisting of Timor, Rote, Flores Programme has not yet reached, high and others; the provinces of East Timor and prevalences could be found. Sri Oemijati et a1 the southern part of the Province of Maluku in the years 1980-1984, found among the (Moleccas). This parasite was first reported native people on the island of Buru an Mf rate from East Timor, then was still a Portu- of 70% and a diasease rate of 47%13. A1- guese colony17 . The fmdings in In- though it may be found in urban areas, fila- donesia was first reported by Sri Oemijati and riasis is mostly a problem in the rural areas, Lim Kiat Tjoan in 196618,followed by other affecting the people of the low socio- reports as results of more detailed studies. So economic group. It is also a lowland disease far no reservoir hosts have been discovered; but may be found in some of the hilly areas. as vector An. barbirostris have been con- So far 3 speccies of at least 5 epidemiologi- firmed. cally different types have been identified. Many nonhuman filarial worms are Wuchereria bancrofri is prevalent both in prevalent in Indonesia. Among these B. urban and rural areas. The urban type is low pahangi and W. kalimantani are the ones endemic in some urban areas as Jakarta and resembling the human parasites19. These Semarang, and has as vector the urban parasites may infect man but the diagnosis is Culex quinguefasciatus. The rural difficult to confirm. Clinical symptoms of occult filariasis were seen occasionally, and discovered, the case will never be diagnosed treated while no correct diagnosis had been correctly, or only suspected, based on the established. clinical symptoms, as occult filariasis, Vis- Mostly found as resevoir hosts are the Pres- ceral Larva Migrans, creeping eruption and bytis cristatus and cats. others. Therefore more sensitive methods need to be developed to be able to make a Angiostrongylus cantonensis correct ethiological diagnosis. Angiostrongylus cantonensis, the causa- tive agent of eosinophylic meningitis is REFERENCES prevalent in Indonesia, mostly in rats 20,21 . 1. Bintari Rukmono, Sri Oemijati, Lie Kian Joe and The parasites have been reported from North Pumomo, 1962. The prevalence of parasitic Sumatra, South Sumatra, Lampung, West infections in infants. Proc. UNESCO Java, Central Java, North Sulawesi, Central Regional Symposium on the scientific Sulawesi, East Nusa ~en~~ara~~.The follow- knowledge of Tropical Parasites Singapore. ing animals have been reported harbouring 2. Lie Kian Joe., Bintari Rukmono., Sri Oemijati, K. Sahab, K.W. Newel., Sie Ting Hway and W. the parasites: Rattus rattus diardi, R. exulans, Talogo., 1966. R. tiomanicus jalorensis, R. lepturus, R. nor- Diarrhoea among infents in a crowded area of vegica and Bandicota indica setifera. Lim et Jakarta, Indonesia. Bull. W.H.O., 34: 197. a1 found in South Sumatra a highest infection 3. Clarke, M.D., Cross, J.H., Gurning. J.J., Sri rate in R. tiomanicus and a lowest infection Oemijati. F. Partono. Hudojo and Hadi. Human malaria and intestinal parasites in rate in R. r. diardi. Kresek, West Java, Indonesia, with a cursory The larvae have been recovered from the serological survey for toxoplasmosis and landsnail Achatina fulica and slugs. So far amoebiasis. South East Asian J. Trop. Med. only t wo clinical cases of eosinophylic & Pub. Hlth., 1973,4: 32 - 36. meningitis have been reported from North 4. Sofyan Masbar and Purnomo, 1977. Preliminary 13 observationsof human behavior in connec- Sumatra and one case of ocular Angiostron- tion with the transmission of Ascaria lumbri- gylus infection from Semarang, Central coides, hookworm and Trichuris trichiura in Java24 . South Kalimantan. First Nat. Parasit. Semi- nat, Bogor. 5. Halimun, G.M., Kartono, D., Hadidjaja, P. and Sri SUMMARY AND CONCLUSIONS S. Margono, 1977. Surgical complication of in children. J. Indon. Med. Ass., 27: In Indonesia, although parasitic infec- 19. tions are generally decreasing, many para- 6. Margono, S.S., C. Koesharjono., and E. Kosin,. sites still constitute public health problems 1979. Hookworm in dogs and cats in the area of Jakarta. Trop. Georg. Med., 31:257-262. especially in the rural and slums and suburbs 7. Wiryadarma K.1.. P. Hadidjaja., Siti Alisah Abidin of big cities. 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Bul. Penelit. Kesehat. 17 (2) 1989 10. Lie Kian Joe and Tan Kok Siang., 1959. Human 17. David, L.H., and F.B. Edison., 1964. Microfilariae intestinal helminths obtained from autopsies of man Portuguese Timor. Trans. R. Soc. in Djakarta, Indonesia. Am. J. Trop. Med. & Trop. Med. hyg.. 58: 6. Hyg., 8 (4): 518-523. 18. Sri Oemijati and Lim Kiat Tjoen., 1966. Filariasis 11. Ilahude, H.D., R. Sasdiono., S.S. Marpono., P. in Timor. J. Indon. Med. Ass., 21 : 67. Hadidjaja., and E.A. Rungun Putuhena.. 19. Palrnieri, J.R., Pumomo, D.T. Dennis, and H.A. 1988. A case of South Manvoto,. 1980. Filarid parasitesof South Kalimantan. Nat. Par. Seminar, Bogor. Kalimantan, Indonesia. Wuchereria kaliman- 12. Hadidjaja, P., S.S. Margono and F.A. Moeloek, tani sp. N. (Nematoda: Filaroidea) from the 1979. from a cervix silvered J. Parasitol. 66 (4) : 6450. of a woman in Jakarta. 20. Margono, S.S.. and H.D. Ilahude, 1974. Angio- Am. J. Trop. Med. Hyg., 28: 161 - 162. strongylus cantonensis in rats and inter- 13. Sri Oemijati. S. Djakaria and Ramschie., 1983. mediate hosts in Jakarta and vicinity. S.E. Filariasis natives in Ruru. IIIrd Nat. Parasit. Asian J. Trop. Med. P. Hlth. 5: 236. Seminar, Bandung. 21. Kwo, E.H. and I.T. Kwo, 1968. Occurrence of Angiostrongylus cantonensis in rats in North 14. Lie Kian Joe and Don M. Rees., 1958. Filariasis in Sumatra, Indonesia. J. Parasitol, 54 (3): 642. Indonesia, distribution, incidence and vec- 22. Carney W.P., E.E Stafford., Purnomo and S. tors. Proc. VlTH Congress Trop. Med. Mal. Tanudjaja, 1978. in In- II: 361. donesia: additional geographic and host oc- 15. Partono, F. and Purnomo., 1986. Zoophylic and currence records. South East Asian J. Trop. anthopophylic : basis and Med. Pub. Hlth., 9516. criteria for separation. VIth International 23. Smith A.M., 1962. Eosinophylic meningitis at Congress of Parasitology. Brisbane, 1986. Kisaran (Indonesia) and the problem of its 16. F. Partono.. D.T. Purnomo. Dennis., Soeroto At- setiology. Bull. Soc. Path. Exot. 55: 722. mosoedjono, Sri Oemijati and J. H. Cross., 24. Widagdo, Sunardi, D.M., Lokollo and Margono 1977. Brugia timori sp. N. (Nematoda: S.S., 1977. Ocular angiostrongiliasis in Filaroidea) from Flores island, Indonesia. J. Semarang, Central Java Amer. J. Trop. Med. Parasitol., 63 (3): 540. Hyg.,26:72.

QUESTIONS PLN9ANSWERS :

1. Question: Trichostrongylus sp. and Strongyloides decreased in recent years. (why) ? Answer : Many parasites have disappeared : may be caused by many factors like sanitation, socio-economic conditions, change of environment, etc.

2. Question: Are there any reports of disseminated in immuno-compromisedpatients? Answer : No cases of disseminated S.S.infection were found in Indonesia. Back in 1956 I have found one case with auto infection showing creeping eruption.