With Reference to Schtstosoma Japonicum

A REVIEW OF SCHISTOSOhlIASIS IN INDONESIA WITH REFERENCE TO SCHTSTOSOMA JAPONICUM

Lim Boo ~iat'and M. sudomo2

ABSTRAK

Tinjauan tentang Schistosoma di Indonesia ini mencakup Schistosonza japonicurn, S. ztrcog~rzr!m~. S. spindale dan Trichobilhmzia brevis. Tinjauan dibuat atas dasar laporan-laporan penelitian yang leiah diterbitkan. Di dalamnya dapat dijumpai uraian singkat tentang S. spinale dan T brevis. Dari banyak pu blikasi tentang S. j~ponicum dan S. incoganiturn dapat disajikan uraian tentang peranan kedua p arasi t tersebut sebagai penyehab penyalut baik manusia maupun hewan

INTRODUCTION ti~~oclinical tor:ns of the disease. the vesical and the intestinal. In the orien- Schistosomiasis, sometimes called tal the disease, which is an intestinal bilharziasis, is one of the most wides- forms, is known as oriental schistosomid- ;>read of' all human parasitic diseases. sis, Kata)-ama fever, bilharziasis japoni- it ranks second in terms of social econo- ca and Yangtze I7alle)- fever. The diseasc mic and public health importance in is accompanied by toxic and dysenteric tropical and sub-tropical areas, immedia- symptoms, as well as loss of appetite tely behind mahria. In terms of preva- and ~veight. emaciation and retarded lence, it takes first place among the qo~-thof youns patients. The most \traters borne diseases, representing one characteristic of the disease, are enia~- oi' the major health risks in rural areas ged liver and spleen, and often ascites of develol~ingcountries. usuall~.more pronounced in the oricntal Schistosimiasis is a three-factor com - form than in intestinal schistosomiasis plex, involving and agent, an interme- 01 Africa, Central and South America. diate molluscan host and a mammalian Four species of Schistosoma have been defenitive host (Fig. 1). reported from this archipelago. The!. It is caused by certain diyenetic are the classical Schistosoma japonicum, trematodes which choose as their habitat S. incogniturn, S. Schistosoma japonicum, the venous system of man. There are S. Spindale and Trichobilharzia brevis.

1. C/0 Institute for Medical Research, Kuala Lumpur, Malaysia. 2 Health Ecology Research Centre, National Institute of Health Rescarh and Development, Jakarta, Indonesia.

Bul. Penelit. Kesehat 15 (3) 198: 1 A Review of Schistosomiasis ...... Lim Boo Liat et al.

F. f 1% I. rife cycle Shistosoma japonicum.

.'L. .'L. Cop'hting pair of S. japonicum inhabiting the upper rnesenteric veins of definite host. B. Intermediate molluscan host, O~comelaniahu.pensis li~doensis.'c. Definitive host represented by man, although any mam?lal th:?t enters infested waters will provably serve as a definite host. Eggs of S, japor:icurn, after being passed from female worm into small veins, make their way into bowel of host, pass out with faces, and, if deposited in aquatic habitat,hatch, and release a motile rniracidium. Xf miracidium comes in contact with an oncomeianid snail, it will pelreirate and go through a series of asexual multiplications resulting in the production of larval worms, known as cercarias. These escape into an aquatic environment, and penetrate :he skin of mammals frequenting that habitat. Within the definitive mamialian host the cercaria metamorphoses into an adult schistosome, mates and, thus, completed the life cycle.

2 Bul. Penelit. Kesehat. 15 (3) 1987 A Review of Schistosomiasis ...... Lim Boo Liat er al.

Of these, S. japonicum is the most impor- miasis area in the Sap11 valley \vas dis- tant in terms of human health and its covercc16. Durins these period, thc bioloa is best understood. this review, intermediate host , Oncomela~ziahupensis brief mention is made of what is known lvas found in the Lakc Lindu vallc). about S. Spindale and T. brevis and then Thus confirmed that the disease situati- the discussion concentrate on S. japoni- o~iin Indonesia \\.as, in fact, .Lform of cum and S. incognitum. The classical classical oriental schistosomiasis similar from of S. japonicum from S. japonicum in its bioloq!. ant1 transmission to tliat like schistosomes of Indonesia and their found in the Philipj~incs.J :li~anand Chi- respective roles in the etiolog) of human na. The lnolluscan host 01's. japonicurn and animal disease are also discussed. in the Lake Lindu \:alle) \vas subsequcn- tl~.described as a ne\z species, 0.h. lit?- doensis and is most similal- to 0.11.quadrasi. the vector host in the ~l?ili~~ines~. CLASSICAL SCHISTOSOMA The disease occurs now only in two ver!. JAPONICUllS isolated areas, the Lake Lindu valle). and Kapu valley in Central Sulawesi. . Prelinimary studies of schistosomiasis in Indonesia were made in the late 1930's and the early 1940's. The first human case of S. japonicum \vas dis- covered by hluller and Tesch from Lindu valley of Central Sula\vesi (Cele- DESCRIPTION OF THE LINDU &ID bes). Early epidemiological studies prior NAPU VALLEYS to IVorld War I1 demonstrated that, in addition to man, wild deer and domestic Detailed descriptions of both these 9 dogs served as reservoir hosts, and sub- valle).s were given by Clarke et. al. and sequent microscopic examination of Carney et. aL6 However, it will be useful adult worms from these mammals con- to summarize some of the salient featu-

firmed them to be S. japonicum 273 A1 res of the areas. though extensive snail surve),s were . The Lindu valley is located in the conducted at that time, the molluscan highlands of Central Sulawesi (Fig. 2). host was not found. The schistosomiasis The valley has an area of approximatel! problem in Lindu Valley virtually 100 km 2' in the Takolekadju mountain remained dormant until 1956. Epidemio- range. In the northwestern portion of logical stadies were made, which confir- the valley lies Lake Lindu, which is 10 med the findings of precious investiga- km in length and average 5 - 6 km in tors4, and since then lake Lindu Valley width. Nun~erous streams originating has been known as the only area of en- from the surrounding mountains empty demic S. japonicum in 1ndonesia5. into the lake. At the northwest corner, S, japonicurn in 1ndonesia5 the Gumbasa river, which is the only In the 1970's there was a resurgence outlet, flows into the adjoining Palu of interest in the epidemiology of schis- valley. Therc are flat stretches of 10~7- tosomiasis in Indonesia. A new schistoso lying marshy areas on the eastern and

Bul. Penelit. Kesehat. 15 (3) 1987 3 A Review of Schistosomiasis ...... Lim Boo Liat et al.

northern sides as well as at the northwest Human population numbering about corner of the lake. These open swampy 1,500 - 2,000 are spread among the areas are utilized by the village popu- villages there, most of which lie on the lation for cultivating rice and grazing western shone of the lake. cattle. Climatologically the Lindu valley Napu valley is also located in the is situated in a tropical rain forest cha- highlands of Central Sulawesi, about racterized by high temperatures and 50 km southeast of Lake Lindu (Fig. 2). humidity.

Fig. 2. Map showing the two known endemic areas for Schistosoma japonicum in Central Sulawesi, Indonesia : Palu Valley and Napu Valley.

4 Bul. Penelit. Kesehat. 15 (3) 1987 A Review of Schistosorniasis ...... Lim Boo Liat et al.

The valley lies between the Takolekedju In the Napu valle), the habitats mountains on the west and the Tineba are mainly swampy fields with dense, mountains on the east, and is now a short or tall marsh grasses, usually dried-out lake bed of more than 1,000 adjacent to actively worked padd>-fields. km2. It is surrounded by tropical rain Forested areas or along the edge of the forest characterized by high teinpcratu- forest have not yet been searched for res and humidit). The valle) floor is the snails. a well-drained gassy plain. 4 small bod) Potential oncornelallid habitat in of water, Lake \Yanga, is situated 5 km Napu valley is far greater than thdt south of Wuasa, the district capital. The available in Lindu ~~alle).I11 Lindu valle) Napu valle) is drained b) the Lariang less than 50 krn2 are lowlands or moors which river empties into the strait of needed for 0. hupensls habitat, whereas Rlakassar. in Napu valley there are 7,500 km2 of Presentl) more than 4,000 people such terrain6. inhabit the Napu valle) in \illages loca- Infection rates of S. japonicum in ted along the Lariang river and its tribu- 0.h. lindoensis varied considerabl! bet- taries. ween foci and between sampling periods. The overall average infection rate in the Lndu valley was 2.4 % in large disturbed ECOLOGY OF ONCOMELANIA area foci, and about 7.0 % in small na- SNAILS AND INFECTIVITY tural foci bordering the lake shore or in the virgin lowland forests. Infection rates Foliowing the discovery of a single were higher in females (2.70 %) than in specimen of Oncomelunia snail in 1971 male snails (1.95 %). Cy age (length) by Carney et. a~.~,further intensive snail infection rates were quite consis- surveys revealed over 70 foci of this snail tent in snails two months of aqe 01- were found on the lowlands surrounding older1 the lake Lindu area1 O and 15 foci in Napu valley about 50 km southeast of ~indu'l '. The ecolog) of this EXPERIMENTAL INFECTION snail is well documented by these inves- STUDIES tigators, and later also by Pinardi Hadi- djaja and ~udomo'3. The subspecific Studies on experimental animals, status of the Onwmelania in the Napu using mice, Wistar rats, Long Evans rats, valley has not been determined as yet. hlongolian gerbils, wild rats (Rattus and is presently referred to at the Napu norvegicus), hamsters and guinea pigs geographic strain of 0. hupensis. showed that mice were found to be the In the Lake Lindu valley, most of most susceptible experimental host for the Oncomelunia colonies isolated have the Indonesian strains of S. japoni- been found on the 1 estern and northern cum1 5. side of the lake. Cc onies of this snail Experimental studies on subspecies were found near cultivated fields, aban- of 0. hupensis exposed to infection ~vith doned farming areas and in the unculti- zoophilic and anthropohilic strains of vated virgin forests surrounding the lake. S. japonicum to determine the abilit)

Bul. Penelit. Kesehat. 15 (3) 1987 5 A Review of Schistosomiasis ...... Lim Boo Liat et al. of geographic strains of the parasite subspecies to infection with geographic were carreid out by Cross et. al. The zoophilic and anthropophilic strains of snails, 0.h. quadmsi from Philippines, S. japonicum. Most species of snails 0.h. formosa and 0.h. chiui from Tai- can be infected with geographic strains wan, 0.h. nosophora from Japan and of the parasite from other areas, but 0.h. lindoensis from Indonesia were usually in low numbers. Others such used for these experiments. Anthropo- as 0.h. quadrasi from Philippines and philic strains of S. japonicum from Phi- 0.h. formosa from Taiwan are essentially lippines, China, Japan and Indonesia, resistant, but 0.h. chiui ,from Taiwan and zoophilic strains from Taiwan were seems to be a universal host easily be- used to infect these different geographic coming infected with all strains of S. strains of snails. The results show the japonicum (Table 1). diversity specificity of 0. hupensis

Table 1. Deveiopment of geographic strains of Schistosoma japonicum in various subspecies and strains of Oncomelania hupensf

------OncomeIania hupensis Geographic strain of Schlstosma japonicum subspecies Philippines Taiwan China Japan Indonesia Bohol Leyte Changhua Ilan

0.h. quadmsi (Bohoi) 1 4,028 558 loo i 447 I 396 1 419 No. exposed 1 2,148 :& 1 430 65 253 1 290 354 No. survived 6 34 100 3 5 6 5 43 01 NO.positive (%I* (30) (8) j (2) (2) 1 (12) 0.k. quadrasi (Leyte) 717 1 2,715 631 90 1 368 386 1 46 9 No, exposed 1 576 2,271 1 532 77 1 230 i 321 394 No. survived 2 483 O[ 0 1 1 6 6 No. positive (5) 1 (0.4) 1 (21) , (1) (0.3) 0.h. quadran' (Mindanao) 767 496 470 - 1 392 250 526 No. exposed 1 606 320 329 - I 395 1 230 / 378 No. su~vived 1 1 - 0 0 No. positive (%) O (0.3) - 1 1 I I O i 0.h formosana (changhua) 1 I No. exposed 639 / 621 3,255 490 677 470 5 94 No. survived 1 543 502 2,4511 53 417 No. positive (%) ' 0 7 490 (0.2) (1 (19) 0.h formosana (Ilan) No. exposed 400 396 No. survived 272 356 362 894 No. positive (%) 9 4 12 46 4 (3) (1) (3) (5) (0.9) ( 2)

6 Bul. Penelit. Kesehat. 15 (3) 1987 A Review of Schlstoaomfasis...... Lim Boo Liat d.

Geographic strain of Schistaroma /apontcum Oncomelunio hupensis subspecies I Philippines Taiwan I I I I I I China I Japan I Indonesia

: 0. h. chiui (Alilo) No. exposed 818 No. humived 1 814 1 634 (70) 405 i 1 NO.positive 327 (50) (5 2) I I 0. h. quadrasi (China) 1 No. exposed No. survived No. positive (%)

0.h. nosophoru (Japan) No. exposed No. survived No. positive (%)

U. h lindoensis (Indonesia) No. expoaed - No. nmived - No. positive (%) -

* Numbers in parentheses are percentage positive for cambeto nearest whole number (Cross et. at, 1984).

These experimental studies clearly phic strains of S. japonicum while 0.h. show that the anthropophilic strain of quadmsi from the Philippines were sus- S. japonicurn from Indonesia can infect ceptible to the Philippines strain of S. a wide diversity of geographic strains of japonicurn, and refactory to the other Oncomelania snails. three strains of S. japonicum. Subsequent experimental studies on The results of this study differs from four subspecies of 0. hupensis, namely, Cross et. a1.16 in that the S. japonicum 0.h. lindoensis, 0.h. hupensis, 0.h. strain of Indonesia was shown to be not nosophorn and 0.h. quadrasi exposed a good experimental host for 0.h. hu- to miracidia of four geographic strains pensis from China, while the reverse of S. japonicum, i.e. The Chinese, Japa- was found in Sudomo experimentati- 17 nese, Philippines and Indonesia were on. carried out by ~udomo'7. He found that The survival infectivity of the In- 0.h. lindoensis from Indonesia and donesian strains of S. japonicum at 0.k. hupensis from China to be the most different temperatures to its natural susceptible among all the four geogra- host, the 0.h. lindoensis was carried

BuL Penelit. Kesehat. 15 (3) 1987 7 A Review of Schistosomiasis ...... Lim Boo Liat et aL

out by sudomol '. He showed the miin the transmission of this disease, be- racidia were active and infective at cause humans, domestic and wild ani- three different temperatures at 18OC, mals all frequent areas, which harbour 23OC and 28OC from 0 - 8 hours. At the molluscan host and leave their excre- 1a6cthe rniracidia were still active at ta in the amphibious or aquatic habitats. the age of 24 hours, although the infection rate was comparatively low. At 23O C the miracidia were still infective DISEASE PREVALENCE IN HUMANS from 0 - 12 hours whereas at 28OC rniracidia were not able to withstand The distribution oi schistosomiasis the temperature longer than 8 hours. throughout the Indonesian archipelago was studied txtensively in the 1970's. 3vIiihilL'fALSRESERVOIR HOST i.xpecialIy on the island of Sdawes:. A!thoi~qh Inore than 50,000 stools i..nc. of course, is one of tile predo- specimens were examlned and extensive minant mammals in the Lake Lindu val- surveys conducted Schistosoma japoni- ley serving as a reservoir host. Surveys on cum and Oncomelania Izupensis appear wild mammals revealed S. japonicum limited in their respective distribution naturall) infected 13 of the 23 mammal to two contiguous drainage systems SF\-ciesexamined. They are the field and of Central Sulawesi, i.e. the Lindu valley, forest rats: R. exulans, R. hoffmanni, 1,000 meters in elevation at the head- R. chpsncornus rallus, R. rnarmosurus, waters of the Gumbasa river drainage R. celebensis, wild deer (Cervus timoren- system and the Napu valley, more than sis), wild pigs (Sus scrofa), wild civet 1,000 meters in elevation at the head- (Yiuerra tangalunga), forest shrew (Cro- waters of the Lariang river drainage s) s- cidura nigripes), domestic cow, dog, tem. carney2' speculated that at least horses, and water buffalo1 3 O. Marn- 7,000 individuals are continuously expo- ma1 surveys have been geared to deter- sed to schistosomiasis in confirmed en- mine the distribution and infection rates demic areas. in rodents, principally R. exulans, which Since 1971, extensive and intensive inhabit the cultivated lowlands of the surveys were narrowed down to the two disease foci in the Lindu area. Routine foci in the Lindu and Xapu valleys of fecal examinations of wild and domestic Central Sulawesi, and a summary report mammals were shown to be significant is presented in Table 2. In Lindu valle)

Ful. Penelit. Kesehat. 15 (3) 1987 A Review of Schistommiasis ...... Lim Boo Liat ct a!.

Table 2: Summary of Schistomma japonicum infection in villages of Lindu and Napu valleys, Central Sulawesi, Indonesia.

Area Villages surveyed Total Number of Percentage References population stools positive examined

~induvalley, Tomado, Langko and Anca 1,458 126 53 Pinardi Hadidjaja aL, Central Sulawesi 1972.

Lindu valley, Anca, Tornado, Langko and 1,500 1,417 37.9 Clarke et aL, 1974 Central Sulawesi Puroo Lindu valley, Anca, Tomado, Langko, 1,515 1,423 37.5 Central Sulawesi Puroo and Paku Napu valley Watumaeta, Wuasa, Alitupu, 1,843 583 43 Carney etaL, 1974 Winowonga and Maholo Napu valley Kaduwaa, Tamadue, Sedoa 1,214 1,003 31 Carney etal., 1977 and Watutau Napu valley Maholo, Winowanga and 708 24 1 65.9 Pinardi Hadidjaja et.aL, Tamadue 1985. Palu valley and Ruwali and Pakuli 7,000 2,433 0.8 Crosset.al, 1975 Lindu valley, Central Sulawesi Rampi and Singkalong, Eno and 640 640 0.9 Carney etal., 1977 Seko valley, Dodolo South Sulawesi

93.9 % of 1,515 inhabitant among the clinically compromised by this infection. villages surveyed in 1971, 1972, 1974, In Palu valley which is nearby the the infection rates were 53 %, 37,9 % lake Lindu where waters from lake and 37.5 % respectively ' ; * 2. In the Lindu enter the Gumbasa river which Napu valley, a coverage of 50.4 % of joins the Palu river flowing through 1,843 inhabitants among the villages the lower Palu . valley, 2,433 stools surveyed in 1972, 1974, 1980, the in- from an estimated population of 18,700 fection rates were 43 %, 31 % and in the seven villages along the Palu drai- 65.9 470 6* 23~24 . The results showed nage system were examined in 1971. that the prevalence rates vary at diffe- Less than 1.0 % of these stools were rent periods of surveys, and they are positive with S. japonicum eggs and relatively high for each of the period these were from two of the seven villa- examined. It is important to emphasize ges2 s. In 1973, the Rampi and Seko that these numbers and percentages valleys of South Sulawesi with similar refer to persons passing schistosome eggs mountain valleys and geological history in their stools, a much smaller number to that of the Lindu and Napu valleys; and percentage of persons are really human parasites were surveyed in seven

BuL Penelit. Kesehat. 15 (3) 1987 A Review of Schistosomiasis ...... Lirn Boo Liat et al. villages (3 in Seko village an'd 4 in Rampi engineering, mollusciciding, improved sa- village). Only six persons of 640 inha- nitation and heaith education. The re- bitants in the 3 villages at Seko valley sults were good as the prevalence of were found with S. japonicum eggs schistosomiasis was reduced from 70 % in their stools26. A follow-up investi- to 25 % in the intervention area over gation of these positive cases in the a two year period229289 29 . Regrettably, Seko valley by these investigators, however, the control effort has not been revealed that all had recently migrated maintained and one indicator of increa- from the Napu vallej-, a confirmed schis- sed transmission, the prevalence of in- tosomiasis area. fection in rodents, suggests that the di- Stud) on the clinico-pathologic of sease will return to its previous level of infection showed that the positivity of endemicity in a short period. liver biopsj for eggs from 52 S. japoni- Other schistosomiasis control pro- cum patients in the Lindu va1le)- foci jects were conducted throughout the was 96 %' . This finding indicates that Lindu vallej during the same time frame although diagnosis of S. japonicum and subsequent to the NIHRD - \YHO is generally made 5)- stool examination pilot control projects. The non-inter- and rectal biopsy, live biopsy also proved vention area of one stud) was acciden- to be a valuable mcthod of diagnosis taly "controlled" by another project as well. obviousl~ compron~isingthe results of Since 1971, all these studies ha1.e both studies. In addition 4 - 5 villages conclusivel>. demonstrated that the di- in the Linclu valle) have been treated sease and its molluscan host are well by a number of agencies on more than established in the undisturbed lowland one occasion using morc than one anti- forest. The presence of the disease and schistosomal compound making it diffi- large population of the snail In disturbed cult to determine who has been treated, and cultivated areas appear to be secon- with what, b? whom or when. dary adaptations.

DRUG TRIALS CONTROL PROGRAMME hlass and selective treatments with Since 1975, there have been a num- different antischistosomal compound, ber of developments that have changed such as Niridozole, Stibophen and Pra- the epidemiological picture-some for the zigruantel were carried by various inves- better and some, regrettably, for the tigators at different time period in the worse. focus area. The results show that 11 A pilot t~ntrolproject was initiated patients treated with Stibophen did not by the National Institute of Health passed ova in their stools 2 and 6 months Research and Development (NIHRD) in after treatment, and 11 months post conjunction with the World Health treatment follow-up, one out of 10 Organization (WHO). This pilot project patients passed ova. In the case of Niri- which focussed on the Paku-Anca area dozole treatment to 31 patients, 4 pas- involved selective mass treatment, agro- sed ova after 2 to 6 months post treat-

BuL Penelit. Kesehat. 15 (3) 1987 A Review of Schistosomiasis ...... Lim Boo Liat et al.

Table 3. Resewoir and intermediate host of Schistosoma species in Indonesia.

1 I Sch~stosoma, Reservou hosts Intermediate host< Locabons Reference spec~es (mammals b bud) (moUushc) I I i I 1 Scli~srosonzc 1 Domestic mammal , I spitidale i Nater buffalo / 1 Planorbid snails North Sumarrr! Hu~paa!: 1935

Trichobi1iza:io ? ducks Rad2.y /Li 17i11oeo1 la1 ariicc I Aaru. best Jal, Ilarronc. S.S. 1968 I bre ris Field 6 forest Rodents Radix (LI rn~~acaiaurlcuiaru Cikura Mest Rarrus argenrli3etlrcr ruhrarr7oz Rarrirr exulatis Lake Lindu an3 R I~atrmarii lapu \ alle? s. ' R 171rldrrr C ennal Sulawes,

1 bild deer Ceri.iis ~I~~~O~EIISIS , Lynlnaeid snaik Paso valle? . Bonne et.al.. 1942. Central Sulanesi I ausi h Honnc 194h

Llndu \ allel. N4uller A Tezcfl lQ3' Central Sulaaes, Bonn? et al 1932 Brur A Tescll. 193' Bruck b Ilhrnman 1956 Llndu b \a;>u \alie>-s. Carrie! e;.d.. 1073~ Central Sul-a-es: Sudonio h Carnr~ 1971 Rodents

Insectivore Crosrdirro rigrlpes & ild deer Ccrl us rrrnorc~ia~ 14 lld plf Slis scrorc I b ild vicrt I 11,ew1 tatigalunpc I Domcttr nlarnmal. bater buffalo I con. do:. Horsec I L I

Rul. Penelit. Iiesehat. 15 (3) 1987 A Review of Schistosomiasia ...... Lim Boo Liat et al. ment, and 11 months follow-up treat- hosts, caution should be taken not to ment 5 were still observed to pass ova3' introduce any new elements, particu- Mass treatment of 708 people in three lary translocation schemes of people villages of Napu valley with praziquan- within the local province and country tel showed significant reduction of pre- transmigration programs in both the valence rate from an average of 15 % Lindu and Napu valleys endemic schis- pretreatment to 2 % six months post tosomiasis areas. treatment24. The side effects of the 3 antischistosomal drugs to treated patients, showed praziquantel has the least Schistosoma japonicum like trematodes side effects as compared to the other There have been several records of two drugs. It was apparent from these Schistosoma japonicum like infection studies, praziquantel is the drugs of reported in Java outside the lake Lindu choice for the treatment of S. japoni- and Napu endemic foci. Cases of S. ja- cum in the endemic area. ponicum infection from Indonesia usually area considered non autochthonus as almost all have occurred in residents of Chinese heritage who have previously POTENTIAL SPREAD OF migrated from or made trips to mainland SCHISTOSOMIASIS BY china 31,32, 33, 34, 35, 36 onecase, ENVIRONMENTAL CHANGES reportedly made numerous trips to Central Kalimantan (Borneo), staying A logging road has been constructed there for 3-4 month periods. However, from the Palolo valley close to Bamba this individual, also of Chinese heritage,. which is confirmed schistosomiasis trans- denied every having been in endemic mission area on the northern shore of areas of Sulawesi or having travelled lake Lindu. The only reason schisto- outside of ~ndonesia~~.Another case somiasis is not a major health problem that has recently been reporter! invol- in Indonesia today is because of its ved a man of Chinese heritage who very focal and limited distribution. It denied ever leaving the island of ~ava~'. has the potential to be a much more All these cases occurred in middle or serious health problem. Increased con- older age male between 34 and 68 tact with the outside world - as by a years of age and each case was diagnosed commercial road to the valley - would following histological examination of be the most sure way of spreading schis- tissue samples which were recovered tosomiasis to other areaas of Central from surgical reasons or at autopsy. Sulawesi. The present isolation of the Essentially then, these occult cases were Lindu and Napu valleys is the single most important location for its limited due to S. japonicum or S. japonicum distribution and its relative low impor- like tramatodes. The possible explana- tance as a national health problem. tions for the etiology of these cases In the absent of a more effective are : method in the control of the transmi- 1. They may have come in contact ssion cycle between the molluscan inter- with a classical strain of S. japonicum mediate and wild mammal .reservoir in a transmission area of Indonesia that A Review of Schistosomiasis ...... Lim Boo Liat et a1

has yet to be identified. and seaport rats (Bandidota i;.lJicc and 2. The) may have ~isitedon ende- Rattus norvegicus) from Thailand, and mic area of classical S. japonicum, Harinasuta and ~ruatrachue~~added such as China, but choose not to admit forest rats (Rattus berdmorei and the fact, and. Rattus r. tlzai) to the ~ilammalian 3. The). may have been eslwsed to host list ill Thailand. an unknown S. japonicum like trema- In I~~tioneis~i.a mammalinn schisto- tode that is endemic in Ja1.a and/or Ka- some. apj)roj)riatel\- called "The Lake limantan. Pose Blood Fluke" \vas isola~ed 111 the cases involwinji indi\id~ials fro111 ly~llnaeid mc~l1~1sl;sin tlic Poso ~vhohad migratetl fro111 China or who valle! of central Suls\zcsi. b~~rits sl)cci- , had 1-isited that countr) the most fit status \.\.as not determined 3345 Du- probable explanation is that these 1973/19;4. S. ir~cognitu171 \vas individuals were exposed to a classical reported 111 ricefield rats (Rattus argen- strain of S. japonicum in China. Hoize- tiventer)from Cikurai. \\'es~J a\-a. and in ver, the t\co cases iv11o never ~isited Ra~vasariin Jakarta 46.4'7. Subsequen- knojvn endemic areas either in or out of TI!-. the parasite was a~ainSc>und natu- Indonesia, are more difficult to explain. rall) infected in three specics of field .All three of the above options must be an-1 forcst rats (R. exulans. R. Izoffmanrzi considered. and R. nitldus) and in a \\-ild deer In light of recent studies in hlalaysia (Ceruus timorensis) fronl the schisto- ~vhere Schistosoma japonicum- like somiasis endemic area of lake Lindu and e;ys have also been reported from the Sapu valle!-. Central sula\vesi4 '. Al- 1ir.e~ of aboriSines3' ; where adult 10 though a \vide variet). oi' I-, ~dcntsancl a Izorms indistinguishable from S. japo- \vild deer ha1.e been found naturall!- nicum Lvere reported in monke)-s (Ma- illfected with the parasite in Indonesia, aca faicicularis ) in Ranau area of human infections ha1.e not been diazno- ~abali~'and three imported cases of sed by stool exaininations in area \vhere a similar etiology for cases in Indonesia, it is enzootic. particular!. Java and Iialimantan, takes on a new credibility. L).mnaeid mollusks are the on1)- Schistosoma incogniturn. cnnfirmed molluscan hosts of S. incog- Shistosoma incogniturn was described nitum. Lymnaea luteola (Radix luteola) from human fecal specimens collected was incriminated as an uitermediatc in 1ndia4'. Since then, Indian parasito- host of. S. incogniturn in 1ndia4' and this logists have found it naturall!. infected subsequentl\- was confirmed42 I11 Thai- dogs and pigs, as well as from a \vide land. Lymnaea auricularia rubigmosa range of ex1)erimental hosts includin; (=Radix a. rubisnosa) was considered pigs, sheep, goats, cattle, rabbits, guinea as an intermediate host S. zncogni- pigs, rats, mice, dogs and cats4'. 3lost In Intionesin. natul-a1 ini'cctions recentl)., Lee and ;~\:)koff4' found \\.it 11 S. incopniturn larval stages wcrc S. incogniturn to be enzootic in field o\-ser\ccl onl! in R.Q. rubiginosa. This

Bul. Penelit. Kesehat. 15 (3) 1987 A Review of Schistosomiasis ...... Lim Boo Liat et al. wits further confirmed b)- laboratory i11)1>. ;tf'f'cct the hybrid's ability to inlcct cspcri~ncnts in which miracidia uf 3 \vide range of intcrmc(1iatc or tlef'initc S. incogniturn were exposed to labora- Irosts. Ir thcsc sy~npntricscl~istoso~ncs tor).-bred R.a. rubiginosa, and shcd ccr- whicl~sl1;trc tlrc s;lmc gcogritl)hic region 4 8 cariac 41 - 48 days post exposure . it1 Intloncsia 1i)~bricIizesi~ccessfully, thc 'This fitthcr confirmed that thc I-csitlts could be offspring capable of i~itermctliatc host of S. incopnitunz i~il'ccting humans yet also ccpable of ill 111tloncsi;t is the samc molluscan host sl>ccics (R.u. rubiginosa) as that In tli:tt even human schistosomiasis cstablishcd in Thailand. coitlti bccolnc a problcni throughout In Intlonesia, S. japoi.zicum and S. all of' tlsin. inwgnitum have been shown to share Schistosoma spindale thc samc geog~apllicarea and hosts in Schistosoma spindale was thc first the Lindu and Napu valleys schisto- rcl)ortc(i scliistosomc from Indonesia. somiasis cndcmic arcas of Central Sula- In 1935, this blood Ilukc was rccovcrcd \vcsi. 111 t\vo cases both schistosomcs from ~vatcr1)uflalos in Northeast Sunia- s1)ccics were concurrent1)- routic1 in tcrits itnt1 to our knowlcdgc this is the salnc rodent host (R. exulans) and ' tlic onl). writtcn docitmcntation of this in one 01' these cases a heterologies 1)lootl fluke in Indonesia. It is most pair- a S. incognit~tnz male and a likcly that the distribution of tllis S. japonicunl I'cmalc were found in l~arasitc is much wider and probably coI)i~la46Sitbsccjuently, this samc phe- includes Sumatera, Java and I.; a 1' man tan. nomenon \vas obscrvctl in csl)erimcntnl Ucsicics S~tmntcra,S. spindale is kno\vn xni1n:tls. li~ljorator!. mice \\,ere es~)osc(t to OCCII~.ill India, Ceylon and Thailand. LC) 50 S. incoqniturn ccrcariac from \Vest '1'11~p;tr;tsite is responsible Tor cercarial Java and challcngetl with 50 S. japoni- dermatitis "swimmers itch" in an) arca cum cercariae fro111 Ccntral Sulawesi 01' I~ldoncsiawhcrc it is cndcmic and it 40 clays htcr. \Vhen perfitscd 48 da)-s is itlso clsc\\~lierc in Asia. It is a caiisc ;il'tcr cli;~llcngc fit~nttlc S. incogniturn of bovine nasal g1;~n~rlomain nrcas \vcrc L'ou~~tlin thc synccoplioral cad of Asia wl~crcit occurs. Larval stagcs of S. japonicum ~nalcsanti vice vcrs;r. of S. spindale develop in planorbid I Ictcrolo~ously paircd fcinales of both ~nollusks clsc\vhcrc in Asia, anti it is species contained eggs whicl, wcrc of' most likcl). that ~)lanorbic\sarc rcspon- n~atcrni~lorigin50 'The vii~bilit\, of' siI)Ic for the development of thc larval tl~csceggs, i~nl'ort~tn;ttcl).was not cletcr- stages of S. spindale in Indonesia. 1i11. 1i1, cvcn though these two m:tmln;tlian scl~istosomcs have I~ccn Trichobilharzia brevis mctIi:~tcI~ost spcciricity, thcir sj~lnpatric Trichobilharzia brevis is an avian clist~ii.,~tio~~, I,otli gcograi)liicall~~and in blood fluke. In Indonesia the parasite rcg:irtls .it Icitst some tlcfinitivc hosts, was rc~)ortetl only oncc in lymnaeid 1)rcscnLs ;I n;tti~~.;tio~)~)orti~nit). I'or re- ~nollt~sksfrom Jakarta arca of llrest co~nl)inittion of gc~icsthat may favour- . Tllo clcfinitc hosts arca usllally

Bul. Penelit. Kesehat 15 (3) 1987 A Review of Schistommiasis ...... Lim Boo Liat et al.

ti~~cks.The larval stages dcvclop in well as in experimentally infected 1ymn;lcid niollusks wllich arc common rodents. Human are constantly exposed tllro~igli0~11the Indonesian archi~~cl:~go, to the cercarial stage (the infective especially in rice growing areas. It causes stage) of S. incognitum in rice fields c-crc;~rii~ltlcr~n;~titis in R~C;IS wllrrc it of Asia where lymnaeid snails and is clrtlclnic. Its distribution is most commensal rodents maintain this syl- likcl). wicicsl)re;~tl t hro~ighout thc wes- . . vatic cycle of this blood fluke. Evoluti- tern h;~11' 01' Inciollcsin as it was origl- onary pressure is always present and n:tll\. dcscril)ccl from d~~cksand lymnaeid with an). favorable changes in its gene ~nollitsksof \vcstcrn hlala).sia5 . pools, S. incognitum may be able to exploit the second most common mammals in Asia-man. Schistosoma spindale and T. brevis are very host CONCLUSION specific. The former species appears Tl~canimal rcscr\,oir and inolluscan to be restricted to domestic mammal, intcrmctliatc I~ostsof the four schisto- and the latter is an avian blood fluke. It is most likely that there are still somcs ill Intioncsii~ is presented in 'J';~l)lc1 . :21no11gt licse four Schistosonza unidentified schistosomes in addition spccics, the classical Schistosoma japo- to the four known schistosomes in the rlicurn is thc on]). onc which afl'cct Indonesian archipelago. In regards to I 11 ilitio to infecting a vast human health the primary concern is v:lrict). of tlo~ncstici111tl wild mammalian the classical oriental schistosomiasis hosts. The tiistril)~~tionol' classical S. which presently is limited to two remote japorzicum is limitcd to t11c clistrib~~tion mountain valleys of Central Sulawesi. of 0. hupcnsis and this spccics is ver!. It is of utmost importance that a ra- 1.'15 .,' I( 1'1o11s in its cco10gic;ll rccluirc~iicnts. tional control or eradication program S. incognitunl, on the othcr Ilancl, al- be developed before economic exploi- t11ot1g11 it has not l~ccnSountl in miin, tation of Sulawesi spreads this disease I)ut likc S. japonicurn, it lacks dcSini- to other areas. The potential second tivc I~ost spcci1'ic:it 1, ;IS it can dcvclop public health concern involves schisto- in iit least sis orders of mammals in Asia, some of mammals other than man which ant1 in Intioncsia it has bccn rcported ma). adapt themselves such that they ex- in Soiu- species of rodents and a specics ploit or utilize the human population in oC wild dccr. It is atlaptcd to ubiquitous areas where they are now enzootic l>,mnacicl snails potentiall), has a much for their own survival. The schistosome \vitier ciistribution in Asia and elscwhcrc species which is of particular importance tlli~n classic;~lS. japonicum bccnusc of is Schistosoma incognitum. If this ever the latter snails dependence on 0. hu- occurs, schistosomiasis in Indonesia pensis for transmission. In Indonesia, could become a major public health this schistosome share the same defini- problem. tive hosts in the same geographic region Classical oriental schistosomiasis in and heterologus mating of both S. Indonesia is controllable or managable japonicum and S. incognitum was and possibly eradicable disease because found in naturally infected rodent as of its current limited and isolated

Bul. Penelit. Kesehat. 15 (3) 1987 15 A Review of Schistosomjasis ...... Lim Boo Liat et al. distribution in an underpopulated island It was better unfortunate that no of the Indonesian archipelago. Before follow-up of intervention methods being any other attempts are made to control, planned after having found that the manage or eradicate this disease in multidisciplinary approach pilot control Indonesia, it is imperative to re-examine project was promising in the control and re-evaluate past experiences of con- of schistosomiasis in the endemic areas. trol programmes already carried out in Based on the experiences on the pros regards to the feasibility and probability and cons of the successful pilot con- of success of those programmes. trol project, a better intervention control a. In 1974, pilot control multi- method could be made to further disciplinary approach in Anca and reduced the transmission levels, and be Langko foci of Lindu valley which incooperated into the general \.ector- consist of: (1) reduction of one source control programme b~-the government. of infection by treating positive human b. In 1978, two rounds of mollus- cases; (2) reduction of the intermediate cicide trials, usins Bayluscide was carried molluscan host population by sprayins out in each of the Anca and Paku areas foci of transmission with a molluscicide of Lindu valley against moluscan host. and by modification of snails habitat 0.h. lindoensis. The trials were conduc- by agro-engineering technology; (3) re- ted in sequence. In the first round of duction of human contact with infec- spraying, the densit!. of snails was tious cercariae in infested waters b) suppressed b>. 30.7% (fom 89.9 to 59.2 promoting environmental sanitation and snails per m2),and in the second round health sanitation was carried out jointl) it was further suppressed b~.67.2% by the National Institute of Health (from 59.2 to 19.4 snails per n12 ), Research and Development, hlinistry of In the Paku area, the density of snails Health, Republicc of Indonesia and the was reduced by 16.1% in the first World Health Organization. round of spraying (from 90.3 to 74.2 This pilot control project was con- snails per m2), and substantially redu- ducted over a two years period and the ced by 94.3% in the second round results were considered a success as the (from 74.2 to 4.2 snails pel- mm2). prevalence in the human population The overall suppression of snail densit). that was theated decreased from 71% in the combined two rounds of spraying to 26% and the incidence of new cases in the -4nca area was 78.4% (from 89.9 was approximately one-third that of to 19.4 to 19.4 snails per m2) and that the non-interventioned control area. A of the Paku area was 95.3% (from more sensitive indicator of transmission 90.9 to 4.2 snails per rn2). The infecti- changes, e.g. infection rates in commen- vity of the snails in the Anca area was sal rodents, also decreased during this reduced b). 78.8% (from pre-spray of &$-- period by 50%. However, as this control 3.4% to 0.7% post-spray), whlle that in project was only a pilot project inter- the Paku, it was reduced by 32.3% (from vention methods were relaxed following preZspra!. of 1.30% to 0.88% pos spray). the trial, and schistosomisias transmi- In the control villages of both these sion, as expected, returned to the areas, the densjt! of snails and the pre-int ervention levels 2 2 . infectivity rates remai~led consistent

Bul. Penelit. Kesehat. 15 (3) 1987 A Review of Schistommiasis...... Lim Boo Liat et al.

durin~pre and post spraying round 29. transmission cycle completely as long The results of these trials provided as there are other wild and domestic us with a tarser molluscicide compound mammalian reservoir hosts, particularly ~vhich is effective in the control of the rodents. However, intermittent use the intermediate host of schistosomiasis of chemotherapy to masstreat the in the endemic areas. SloUusciciding exposed human and domestic animal would probably be ver). dramatic in the pop~llationcombined with intensive ro- suppressin; of the :ransmission c)-cle if dent control will drastically raduce the the snails habitat is highly restricted transmission. If this type of control in relatively small isolated area. In the effect is maintained the threshold of Lindu 2nd Napu v:~ile).s, the habitats schistosomiasis transmission might be ol the snail co\.er a vast range of habi- reached and the disease eradicated from tats. ranqing from disturbed to undis- the human and animal populations in c~~rbet!forcstetl are:ls. ih~1.s it is not inhabited areas. But, if thc disease is i~m~;icnblcr:, ;:st. moi:uscicide as the left unchecked schistosomiasis woultl :!nit. method of controi [akin? into return with a vengeance. i.onsicieration on the Irequency of Discussion on the pros and cons spraying needed and the cost effecti- of the various control, measure attempts veness. undertaken as above mentioned, it c. Drug trials were carried out in appeares that the multidisciplinary ap- 1974 using niridazole and stibophen on proach which include agro-engineering, 42 'cases with Schistosoma japonicum3 chemotherapy, mollusciciding, health and in 1983 mass treatment with pra- education and improved sanitation for riquantel on 241 infected indi~iduals~~ the control of' oriental Schistosomiasis in the Lindu and Napu valleys. Among is more adequate han the other methods these drugs used, praziquantel was attempted. Unfortunately this type of found to be, the most favoured and control is long term and expensive in drug of choice for treating S. japonicum terms of manpower and public funds. infection in Central Sulawesi. In comparison to other health pro- Schistosoma japonicum lack devini- blems in Indonesia, schistosomiasis is tive host specificity, and develops in a relatively 'unimportant as it involves wide range of mammalian species from less than 10.000 of Indonesia's 167 insectivores to primates. In Indonesia, million residents, and most of those besides man as one of the important infected are not seriously compromised reservoir hosts, at least 5 species of by these blood fluke, but it will remain rodents, a deer including a few genera of a health problem in confirmed endemic domestic mammals also act as reservoir areas. In addition, as the economy of hosts of this schistosome in the endemic Sulawesi grows, means of cornmunica- rea as. Siass chemotherapy treatment tion between the remote areas where it with praziquantel to human cases, is endemic will improve, and the spre- though it is very tempting and encoura- ading of this disease to other areas of ging, and if carried out will obviously Sulawesi where the habitat and mam- have dramatics effect on the human malian fauna are suitable is foreseeable. population, but it will not cut the Thus, it is important alternative methods

Bul. Pendt. Kesehat. 15 (3) 1987 17 A Review of Schistommiasis ...... Lim Boo Lit et al. of control &hich are more economical or temporary change in the water should bc expplored, and suggestion levels. of a few alternatives are as follows: The Lindu and Napu valleys are both geologically situated in partially 1. Declare the endemic areas as a Natio- dried out lake beds. It appears feasi- nal Park. This has been suggested by ble that proper water management the Indonesian Government as the might radically reduce habitats sui- "Lore Kalamanta National Park" table for maintenance of oncomela- hecause of the rich faunal and flo- nids. The Lindu valley appears most ral reserves in this remote areas. suitable for this type of intervention If these endemic areas are closed because of the close proximity of to human settlements, schistosomia- the surrounding mountains. A dam sis will remain as its svlvatic cycle which raised the water level in the 1s wi;ll established in at least 13 Lindu valley only 5 -- 10 meters n~airtmalian species and tlie mollus- would inundate more than 99 % of can host is well established throug- the habitat now utilized by oncome- hout undisturbed, virgin forests as lanids. The new shores of lake Lindu well as disturbed and cultivated would wash against the relativel). areas of the valleys. Human cases of steep mountains surrounding the val- Oriental schistosomiasis would then ley. Potential habitat remaining be limited to isolated cases in visitors would be a small portion of what is v:hose exposure would be minimal available today and could be mana- if adequate preventive measures were ged by conventional methods. utilized. The advantages of a permanent This alternative would necessita- raising of the lake's level would be te moving (transmigrating) the hu- (1) regulation of water for irrigation man population of both the Lindu downstream; (2) hydroelectric powe! and Napu valleys to other fertile production; (3) expandinq fishins areas of Central Sulawesi. The Lindu industry and most importantl?,; (4) valley residents could be moved to reduction of schistosomiasis trans- the Poso valley which is free from mission by destroyins suitable onco- the disease. As Lindu valley residents nlelanid habitats resultinq in a drastic have farmed the valley for less rhan reduction in these snails and com- 100 years they most likely would mensal rodents which are consicle- willingl) move in a well organised red the principal mammalian resel- transmigration project. IIowever, as voirs of schistosorniasis in the Lindu residents of the nearby Napu valley, valle? . where schistosomiasis is also ende- The disadvantages of such a dras- mic, have been settled in that area tic measure would be (1) the neces- for many hundred of years, they sity to transmigrate approximatel) might resist any attempt to transmi- 2,500 persons to another area of grate them to another area. Sulawesi; (2) the flooding of man) 2. Drastic alteration of environment in hectares of fertile farm land; (3) the endemic areas such as a permanent one time, yet initialy high, expense

18 Bul. Penelit. Kesehat. 15 (3) 1987 A Review of Schistosomiasis ...... Lim Boo Liat et al.

of a hydroelectric dam for power that schistosomes and the humw. production and water management. population of endemic areas be al- A related measure that should lowed to maintain a balance of com- also be considered would be the in- patibility. This is definitely a ver) termittent changing of the water economically advantages alternative level of the lake. The principal ad- as it concentrates limited healtt vantages of this drastic alteration reserves for individuals most ir would be (1) inhabitants would need. The disease will be managec only have to move to higher areas but the problem will remain and i! of the valley; (2) intermittent floo- it is not monitored periodicall>-,thc ding would allow for intermittent possiblity of spread to other areas farming of the valley floor and re- of Sulawesi is foreseeable as the eco duction the population of commen- nom): develops. sal rodents. This alternative would Among these three alternatives. initially be expensive farming would alternatives 1 and 2 would be mosl only be intermittent. ideal, but in both cases it involve. The outcome of either of these initially very high capital expenditu. drastic measures would probably be res. In view of the current economic very good, if feasible from the engi- slow - down of the country, alter neering standpoint, for the ecologi- native 3 would probabl~.be the most cal requirements of oncomelanids are suitable temporary. In the long ruli very specific at different stages. the best alternative would be to era- Even temporary yet drastic changes dicate this snail-borne disease in the environment - such as flood- through drastic alteration of it: ing - could reduce the oncomelanid very specific ecological requirement: populations and the populations before it has a chance to spread to of the most important mammalian other areas of the island. reservoir of schistosomiasis, rodents, enough to permanent]). interrupt REFERENCES transmission. 1. Muller, H. and Tesch, J.W. (1973). 3. Treat only individuals with serious Autochthone infectie met Schistoso- clinical signs and symptoms of schis- ma japonicum of Celebes. Genees- tosomiasis. kundig Tijdschrift voor Nederlandsch Even though schistosomiasis is Indie, 77: 2143. considered a serious health problem 2. Brug, S.L. and Tesch, J.W. (1937). in areas where it is endemic, not Parasitaire wormen aan het Celebes) everyone is afflicted with disease Meer (Oa. Paloe, Celebes. Genees- just because he or she harbours cundig Tijdschrift voor Nederlandsch Schistosoma japonicum. This alter- Indie, 77:2151 native involves limited health resour- 3. Bonne, C., Borstlap, A. J. P., Lie, ces be utilized to treat those who K. J., Molenkamp. \V. J. J. and Nan- are compromised by the disease and ning, W. (1942). Voortgezet bilharszii

Bul. Penelit. Kesehat. 15 (3) 1987 19 A Review of Schistosomiasis ...... Lim Boo Liat et al.

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