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Bulletin Penelitian Kesehatan:,'-?alth Studie s in Indonesia

Vol. 11 No . 11974

PILOT STUDY ON THE CONTROL OF MALAYAN FILARIASISIN SOUTH SULAWESI. INDONESIA

Felix Partono and Borahima *

Suatu percobaan untuk memberantas penyakit filaria yang disebabkan oleh Brugia rnalayitelah dilakukan disuatu daerah transmigrasi d i Kecamatan Mangkutanah, Kabupaten Lu wu , SulawesiSelatan.Untuk penyelidikan ini telah dipilih dua desa, Kalaena yang penduduknya selunthnya terdiri daritransmigran dari Jawa Tengah da n Jawa Timur, dan desa Margolemboyang penduduknya terdiri daritransmigran berasal dari Jawa Tengah dan Jawa Timur dan pend uduk asli Sulawesi Selatan.Microfilaria rate didesa Kalaena 33.0 per cen t sedangkan didesa Margo lemboya ng 40 ,s per cent.

Obat yang diberikan adalah diethylcarbamazine (Hetrazan, Lederle) dengan dosis 4 mg./Kg.bb. selama 10 hari.Didesa Kalaena seluruh penduduk yang berumur satu tahun keatas diberikan obat'(n1ass trea tmen t)sedangkan didesa Margolembo pengobatan hanya diberikan kepada mereka yang darahnya mengandungmicrofilaria (selective treatm ent).

Satu tahun kemudian darah dari seluruh penduduk kedua desa tersebut diperiksa kembalidengan hasil sebagai berikut:Didesa Kalaena microfilaria rate berkurang dari 33,O per cent sampai 3,7 per cent, microfilariadensity dari 12,l sampai 0,4 dan MPSO dari 9,9 sampai 5,8. Didesa Margolembo micro,filaria rateturun dari 40 ,5 per cent sampai 9 ,s per cen t, microfilaria density dari 11 ,6 sampai 1 ,7 dan MfD5Odari 10,Y sampai 4.6.Untung rugi mass treatment dan selective treatment dibahas secara singkat. Menurut pendapat

kami didaerah ,filaria dengan derajat endemik tinggi sebaiknya diberikan mass treatment.Successful control of Malayan and bancrof-

tian filariasis by the use of diethylcarbamazinehas been done in many parts of SoutheastAsia and Inslands of the Pacific using variousdosages of the drug a nd diverse regimens(Beye, et al. 19 53 ; Kessel, 19 57 ; Sasa, 19 63 ;Harinasuta, et al. 1 96 4; Ciferri, et al. 19 69 ;Kessel, et a l. 1 97 0 ; Harinasuta, et al. 1 97 0;Ramachand ran, 19 70 ; Kessel, 19 71). Althoughthe diseases have been recognized as pub lichealth problems in Indonesian since 1930(Brug) control measures had not been imple-mented until recent years., This paper reports

This study was supported by funds provided bythe Indonesian Ministry of Health.

The opinions and assertions herein ara not to beconstrued as officia l or as representing the views ofthe Indonesian Ministry o f Health. Department? ofParasitology and General Pathology, Faculty of Me-dicine. University of Indonesia, Jakarta.* Regency Hospital. Palopo, South Sulawesi Pro-vincial Health Service, Indonesia.

the results of pilot experiments on the controlof Malayan filariasis in two small villages inthe Sub District of Margolembo, South Sula-wesi, Indonesia among Javanese transmigrantsand native Sulaw esians-using diethylcarbam a-zine. The purpose of the study was to evaluatemass and selective treatment programs and toobtain information that would be applicablefor future control measures in Indonesia.

MATERIALS AND METHODSThe first village (Kalaena) in which the trialswere conducted had a population consisting

of approximately 2SC Javanest transmigrantsand their descendants who resided in the areasince 1939. A survey of 21 S inhabitants inthis village in 1 970 , showed a m icrofilarialrate of 33 .0 per cen t (Partono, et al. 1972).

The second village (Margolembo) had amixed popu lation o f 1 93 9 Javanese transmi-grants, second and third generation Javanese

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18 FELIX PARTONO A N D B O R A H I M Aand native Sulawesians. The population num-bered approximately 50 0 and a 197 0 surve;of 270 people showed a microfilarial rate of32.5 per ce nt . Since only slightly m ore th anone-half of the population was examined in1970, a second survey was done in January1971 in order to more accurately establishthe numbers of microfilarial carriers. In thesecond survey 365 people were examined anda microfilarial rate of 40.5 per cent was deter-mined.

The drug control program was initiated inFebruary 1971. All of the inhabitants in thefirst village over one year of age were treatedby administering 4 mg of diethylcarbamazine(Hetrazan , Lederle) per kilogram of bo dyweight for 1 0 consecutive days. In the secondvillage a selective program was initiated where-by on ly individuals withm icrofilarem ia receivedthe drug at the same dosage levels as peoplein the first village. Mass treatment was givenin Village I because the people were verycooperative and well disciplined. The dailydosage schedule was preferred because the area

was isolated and travel into it was limited.Prednisone and an antihistamine preparation

(Chlorpheniramine maleate) were given con-commitantly during the first two days oftreatment to mode rate side reactions commonlyassociated with the use of diethylcarbamazine.The people were cautioned that some sideeffects may be witnessed and when the reac-tions occurred they were mild and transientand medically controled. All of the drugs wereadministered under rigid medical supervisions.

To evaluate the program blood surveys wererepeated in both villages approximately oneyear after tre'atment. In all of the bloodsurveys quantitated (20 mm3) finger bloodswere ob tained at night, thick blood films madeand stained w ith Giemsa.

RESULTS AND DISCUSSIONThe results of the study were evaluated by

comparing the microfilarial rates and micro-filarial densities before and after treatment.(Table 1)

Table 1. Microfilarial Rates and Densities in Two South Sulawesi Villages Before and AfterMass and Selective Treatment with Diethylcarbamize.

Pre - treatment Post-treatmentMicrof ilaria Microf ilaria

No. Positive Microfilaria No. PositiveVil loge Population Examined No. Rer cent Density Examined No. , Per cent Density--- ---I b. 1 In Village I in which all of th einhabitants were treated. the microfilarial rates

decreased from 33.0 per cen t to 3.7 per centand th e microfilarial densities from 12 .1 to 0.4 .In Village I1 where the people were selectivelytreate'd the microfilarial rate decreased from40.5 per cent to 9.5 per cen t and the micro-filarial density from 11.6 to 1.7.

Table 2 presents the frequency d istributionand cummulative percentages of microfilarialcarriers for both villages before and aftertreatment. Tb. 2 Th.e median microfilarial

count, MfDSO, for the first village was 9.9and the second village 10.9 microfilariae per20 mm 3. One year later following masstreatment of the population the MfD50 inthe first village decreased to 5.8 and in theskcond village, t o 4.6. Fig. I, 11. (Fig. I and 11).The method described in the Second WHOEx per t Co mm ittee Filariasis (1 96 7) was usedto estlmate the median microfilaria densityfrom frequency distributions of microfilariacounts in a single survey. Probits of the cumu-lative frequencies were plotted against the

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STUDY ON THE CONTROL OF MALAYAN FILARIASIS 19Table 2. C o rn p ara sion o f F re q u e n cy U l s t r ~ b u t l o n f M ic ro f i la r i a l C o u n t s i n Tw o So u t h Su la w es i V i ll ag e s Be f o re a nA f t e r M n r ~ nd Se lec t ive Trea tment w i th D te thy lca rbarnaz ine .

Vi l lage I Vil lage IIM icr oti lar ia (Mass Treatment) (Selective Treatment )Counts Pre-treatment Pos t- treatment Pre- t reatment Pod-t rea tment( 20mm3) Frequency C Frequency C;yzAve Frequency ~ u m u la t h e Fre que ncy Cum ulativeper cent per cent

I 10 14.1 1 12.5 11 7.4 11 27.52 6 22.5 1 25.0 11 15.0 1 30.03 7 32.4 0 8 20.3 2 35.04 3 36.4 0 7 25.0 3 42.55 1 38.0 1 37.5 4 27.7 4 52.56 0 0 4 30.4 1 55.07 1 39.4 0 6 34.4 08 1 40.8 1 50.0 8 39.9 09 1 42.3 0 8 45.3 1 57.510 0 0 1 45.9 2 62.5

11 20 6 50.0 3 87.5 24 62.2 5 75.221 30 4 56.3 0 14 71.6 3 77.531-40 7 66.2 1 100.0 8 77.0 2 87.541 50 9 78.9 10 83.8 051 60 5 85.9 8 89.2 1 90.061-70 1 87.3 3 91.2 1 92.571-80 1 88.9 2 92.6 081-90 2 91.5 1 93.2 2 97.591 100 0 1 93.9 0

101 200 4 97.2 6 97.8 1 100.0201 -300 1 98.6 3 100.0301 400 1 100.0

T o t a l 7 1 8 148 40-- - --, 1a98 - -

a 95 ->.-C.-g 9 0 -a -0.- -Lo80 ---rC2 70

-U.-5 60 - - -

Before0 After -

3 A Mf DsOE(3 5 -I I I 1 1 1 1 1 I I I 1 -1 I I 1 1 1 1 1 1I 2 3 4 5 6 7 8 10 20 30 40 60 80 100 200 300 500

7

6

C.-n5

4

31000

Microf ilarial Count Per 20mm3Fig. I. Regression L lnes o f Curnu la tt ve .Percentage D ls t r lb u t io n o f M ic ro f i la r ia l Den s i t y be fo re and A f te r MasVl l laae I.

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STUDY ON THE CONTROL OF MALAYAN FILARIASIS 2 1had microfilariaemias during the pre-treatmentsurvey but the counts could have been too lowfor detection. O thers may have been individualsin the incubation period and subsequentlythese individuals were - not given treatm en t inthe selective treatment program. Positive indi-viduals that were not examined d uring th e pre-treatment survey were also a potential sourceof reinfection for others and in many instancestheir microfiiarial counts were relatively high.

There were no new comers in Village I.In Village I1 however, the people commonly,moved from o ne village t o an oth er. Four newcomers were found positive; 3 with micro-

filarial counts of less than 10 and one with90 microfilariael20 mm3 of blood.

Side effects to diethylcarbamazine wererelatively few and daily activities could becontinued. The hazards associated with corti-sone were fully realized, however, the mainpurpose of this drug was t o lessen the severtyof side reactions and thus obtain maximalcooperation of the people. This is an absoluteessential for a successful control program.The advantages and disadvantages 'of massand selective treatment are summarised inTable 4.

Table 4. Advantages and Disadvantages of Mass and Select ive Treatment fo r Filariasis with Diethylcarbarnazine.

Tb. 4 In a mass treatment programthe costs of drug and labor for drug dispensingare expensive.These extra cost, however, shouldbe weighted against the extra cost of labornecessary to examine a greater percentage ofpopulation for better recoveries of positiveindividuals. This is highly important in a selec-tive treatment program. It is recommendedthat in future control programs that locallyassembled diethylcarbamazine be used (Filar-zan. Mecosin Co) since it is less expensivethan imported preparations. With selectivetreatment individuals with low counts or in

the incubation period may be misdiagnosed,and not given treatment. Technical errorsduring blood processing and examination maybe another source of misdiagnosis.

Method ofTreatment

Mass

Selective

It is therefore the opinion of the authorsthat in a highly endemic filariasis area masstreatment of the population is more satisfac-tory than selective treatment. Furthermore,in a filariasis control ' program continuousvigilence is important and follow up admi-nistration of the drug may be necessary tomaintain complete control of the disease.

Chances forMisdiagnosis'

None

-Low Counts-IncubationPeriod-Technical

Errors

Cost of

Drug

Expensive

LessExpensive

Post- treatmentMicrof ilar ialCounts

Shifts toLowerCountsUnexamined

Positive1Unaffected

Results

Superior

Inferior

Labor forDrugDispensing

rea at&

L ~ S SExpensive

BloodProcessingSmallerSample1Less~arge;

Sample1More

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22 FELIX P A R T O N O A N D B O R A H IM ASUMMARY and MfDSO from 10.9 to 4.6. The advantage

A pilot control program for Malayan fila- and disadvantages, mass and selective treatriasis using diethylcarbamazine was undertaken ments are discussed and it is the opinion oin a transmigration area in Margolembo, South the authors that in a highly endemic areaSulawesi, Indonesia. Two small villages were the entire population should be treated rathechosen and mass treatment was carried out in than only those with microfilaremia.one village and selective treatm ent in the oth erby administering ~iethylcarbamazine n dosesof 4 mg/kg body weight for 10 consecutivedays. Approximately one year after treatmentthe populations were re-examined and theresults were evaluated b y comparing th e micro-fdarial rates and densities before and aftertreatment. In the mass treated village, themicrofilarial rate decreased from 33.0 per centt o 3.7 per cent, the microfilarial density from12.1 t o 0.4 and the Mf'DSO from 9.9 t o 5.8.In the selective t rea ted village, th e microfilarialrate decreased from 40.5 per cent to 9.5 percent, the microfilarial density from 11.6 to 1.7

ACKNOWLEDGEMENTSThe auth ors wish to than k Dr. Julik Suliant

Saroso, Director General, Communicable Disease Control, Indonesian Ministry of Healtfor financial suppo rt an d encouragementDr. Tajuddin Chalid Director, South SulaweProvincial Health Service for technical supporDr. John H. Cross and Mr. Richard See of thU.S. Naval Medical Research Unit No.2, TaipeiTaiwan for assistance in the preparation othe manuscript and computer analysis of thdata.

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and Bambridge, B. ( 1 9 5 3 ) Nouvelles recher-c h e ~ ur I ' importance, les manifestationscliniques et la lutte contre la filariose aTahiti Oceanie Francaise. Bull. Soc. Path.Exot. 46, 144-163Brug, S.L. ( 1 9 3 0 ) Filaria in Nederlandsch-Indie111. G.T.v.N.I., 7 1, 210-240

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