M ALARI A I N N ORTH SUM ATERA PROVI N CE TH E SI TUATI ON AN D CH ARACTERI STI CS
CH AI RUD D I N P. LUBI S AN D SYAH RI L PASARI BU
D e pa r t m e n t of Ch ild H e a lt h
M e dica l Sch ool, Un iv e r sit y of Su m a t e r a Ut a r a M e da n , I n don e sia
1 . Ba ck gr ou n d
Malaria is a chronic, invalid- producing disease w hich does not direct ly kill m ore t han 1 or 2 per- cent of it s vict im s, alt hough it is oft en a m aj or cause of infant m ort alit y. The disease result s in increasing t he num ber of deat hs from ot her causes and it reduces life expect ancy, except in epidem ic t im es, it is insidious rat her t han dram at ic. Nevert heless over cent uries, m alaria has had a profound influence on t housands of com m unit ies t hroughout t he w orld. But t here is am ple t est im ony t o t he fact t hat m alaria has been one of t he great scourges of hum anit y because of it s delet erious st unt ing of phy sical and m ent al dev elopm ent , it s not orious rest rict ing of
social and nat ional grow t h, and it s blight ing of agricult ure, com m erce and indust ry1.
At present , about 100 count ries or t errit ories in t he w orld are considered m alarious, alm ost half of w hich are in Africa, sout h of t he Sahara. Alt hough t his num ber is considerably less t han it w as in t he m id- 1950s ( 140 count ries or t errit ories) , m ore t han 2400 m illion of t he w orld’s populat ion are st ill at risk.
The incidence of m alaria w orldw ide is est im at ed t o be 300 – 500 m illion clinical cases each year, w it h about 90% of t hese occurring in Africa, sout h of t he Sahara – m ost ly caused by P.falciparum . Malaria is t hought t o kill bet w een 1.1. and 2.7 m illion people w orldw ide each year, of w hom about 1 m illion are children under t he age of 5 years in Africa, sout h of t he Sahara. These childhood deat hs, result ing m ainly from cerebral m alaria and anem ia, const it ut e nearly 25% of child m ort alit y in Africa.
Fat alit y rat es of 10 – 30% have been report ed am ong children referred t o hospit al w it h sev ere m alaria, alt hough t hese rat es are even higher in rural and rem ot e areas w here pat ient s have rest rict ed access t o adequat e t reat m ent . Deat hs from m alaria in count ries out side Africa, sout h of t he Sahara, occur principally in non- im m une people w ho becom e infect ed w it h P.falciparum in areas w here diagnosis and t reat m ent are not av ailable2.
I n I ndonesia m alaria is st ill a m aj or public healt h problem , especially out of Java and
Bali3. The m ort alit y of m alaria in Jav a and Bali w ere 1- 2 person per 1000 populat ion
in 1983, and 10 fold in ot her islands of I ndonesia4.
I n Nort h Sum at era Province, m alaria is not affect ing t he ent ire populat ion, because cases are concent rat ed in som e specific dist rict s. Cases seen in ot her dist rict s are im port ed cases, w ho have visit ed m alaria areas.
I n Nort h Sum at era Province t he Annual Malariae I ncidence ( AMI ) in t he year 2000 is
6.03% , and in t he y ear 2001 is 3.42%5.
Papua New Guinea and Vanuat u. Cross- resist ance t o am odiaquine som et im es occurs2.
Malaria has significant m easurable direct and indirect cost s, and has recent ly been show n t o be a m aj or const raint t o econom ic dev elopm ent . For dev eloping econom ies t his has m eant t hat t he gap in prosperit y bet w een count ries w it h m alaria and count ries w it hout m alaria has becom e w ider every single y ear.
Annual econom ic grow t h in count ries w it h high m alaria t ransm ission has hist orically been low er t han in count ries w it hout m alaria. Econom ist s believe t hat m alaria is responsible for a ‘grow t h penalt y’ of up t o 1.3% per year in som e African count ries. When com pounded over t he y ears, t his penalt y leads t o subst ant ial differences in GDP bet w een count ries w it h and w it hout m alaria and sev erely rest rains t he econom ic grow t h of t he ent ire region.
The direct cost s of m alaria include a com binat ion of personal and public expendit ures on bot h prevent ion and t reat m ent of t he disease. Personal expendit ures include indiv idual or fam ily spending on insect icide t reat ed m osquit o net s ( I TNs) , doct ors’ fees, ant i- m alarial drugs, t ransport t o healt h facilit ies, support for t he pat ient and som et im es an accom panying fam ily m em ber during hospit al st ays. Public expendit ures include spending by governm ent on m aint aining healt h facilit ies and healt h care infrast ruct ure, publicly m anaged v ect or cont rol, educat ion and research. I n som e count ries w it h a heav y m alaria burden, t he disease m ay account for as m uch as 40% of public healt h expendit ure, 30 – 50% of pat ient adm issions, and up t o 50% of out pat ient v isit s.
The indirect cost s of m alaria include lost product ivit y or incom e associat ed w it h illness or deat h. This m ight be expressed as t he cost of lost w orkdays or absent eeism from form al em ploym ent and t he v alue of unpaid w ork done in t he hom e by bot h m en and w om en. I n t he case of deat h, t he indirect cost includes t he discount ed
fut ure lifet im e earnings of t hose w ho die6.
2 . Pr ofile of N or t h Su m a t e r a
Area : 71.680 k m2
Geographical Locat ion
Border on t he Nort h : Nanggroe Aceh Darussalam
Border on t he Sout h : Riau and West Sum at era
Border on t he East : St rait of Malaca/ Malaysia
Border on t he West : I ndian Ocean
Clim at e;
June – Sept em ber : Dry Season
Novem ber – Mar ch : Rainy Season
Dist rict : 13 Dist rict s
Municipalit y : 7 Municipal cit ies
Num ber of Villages : 5.238
Populat ion ( Census) 2000 : 11.722.397
Populat ion Grow t h 1990 – 2000 : 1.20%
Male : 49.98%
Fem ale : 50.02%
0- 4 y ears : 11,49
Rural Populat ion : 56.89%
Urban Populat ion : 43.11%
Households : 2.755.606
Household Av erage Size : 4.25 persons
3 . D ist r ibu t ion of M a la r ia
Regarding of m alaria risk, Nort h Sum at era Province is div ided int o 2 groups; Endem ic Area and Non- Endem ic Area. Dist rict s including in t he group of Endem ic Area are Mandailing Nat al; Tapanuli Selat an; Tapanuli Tengah; Asahan; Labuhan Bat u and Deli Serdang.
M on t h ly Re por t of M a la r ia Ca se s in N or t h Su m a t e r a Pr ov in ce
Ye a r 2 0 0 0
No. Dist rict s/ Municipalit y Tot al No of Cases No of Deat h
1 Medan* - -
2 Binj ai 0 0
3 Tebing Tinggi 0 0
4 Tanj ung Balai 440 0
5 Sibolga* * 630 0
6 Pem at ang Siant ar 0 0
7 Deli Serdang 3166 0
8 Langkat * - -
9 Asahan 9619 2
10 Labuhan Bat u* * 1342 15
11 Sim alungun 2109 0
12 Tapanuli Ut ara* * 261 0
13 Toba Sam osir 99 0
14 Tapanuli Tengah 5227 0
15
16
Padang Sidem puan/ * *
Tapanuli Selat an 6038 0
17 Madina 14773 3
18 Karo* * 1090 0
19 Dairi* * 267 0
20 Nias* - -
Tot a l 4 5 0 6 1 2 0
Source : Depart m ent of Healt h Nort h Sum at era Province * : No significant report y et
M on t h ly Re por t of M a la r ia Ca se s in N or t h Su m a t e r a Pr ov in ce
Ye a r 2 0 0 1
No. Dist rict s/
Municipalit y
Tot al
No of Cases No of Deat h
1 Medan* - -
2 Binj ai* * 0 0
3 Tebing Tinggi* * 0 0
4 Tanj ung Balai* * 297 0
5 Sibolga* * 585 0
6 Pem at ang Siant ar * * 0 0
7 Deli Serdang* * 1306 0
8 Langkat * 0 0
9 Asahan* * 4931 0
10 Labuhan Bat u 5437 0
11 Sim alungun* 0 0
12 Tapanuli Ut ara* * 240 0
13 Toba Sam osir* * 52 0
14 Tapanuli Tengah* * 2210 0
15
16
Padang Sidem puan/ *
Tapanuli Selat an
5319 0
17 Madina 10765 0
18 Karo 1227 0
19 Dairi* 0 0
20 Nias* - -
Tot a l 3 2 3 6 9 0
Source : Depart m ent of Healt h Nort h Sum at era Province * : No significant report y et
4 . Th e Spe cie s of M a la r ia
Since 1997 unt il 2001, t he Depart m ent of Healt h has done a survey of m alaria in som e villages in six dist rict s of Nort h Sum at era Province. The num ber of populat ion w as 6.394 included in t his survey. Blood sm ear exam inat ion show ed t hat m alaria posit ive w as found
in 1.382 cases, t he species of plasm odia being falciparum and v iv ax5.
Th e Spe cie s of M a la r ia in N or t h Su m a t e r a Pr ov in ce
Species of Plasm odia No of
Populat ion
Plasm odia
Posit ive Falciparum Viv ax Mix ed
6,394 1,382 903 458 21
Source : Depart m ent of Healt h Nort h Sum at era Province
During April 2001, Pasaribu conduct ed a st udy of m alaria in 5 villages in Dist rict of Mandailing Nat al. 152 pat ient s of m alaria; 60 cases w ere m alaria falciparum ; 83 v iv ax
m alaria and 9 of m ixed infect ion8.
Th e Spe cie s of M a la r ia
Species of Plasm odia No of Cases Plasm odia
Posit ive Falciparum Viv ax Mix ed
From t hese dat a w e consider t hat only t w o out of four species of plasm odia is of nat ural parasit es of m an in Nort h Sum at era Province t hat is falciparum and vivax. There is no report about ovale and m alariae species in t his area.
5 . Clin ica l m a n ife st a t ion of m a la r ia pa t ie n t s
From hist ory, t he m ost clinical sym pt om s w ere fever ( 97% ) , pale ( 80% ) , headache ( 55% ) , diarrhea ( 42% ) , and j aundice ( 13% ) respect iv ely. On phy sical exam inat ion w e found t hat
27 pat ient s had splenom egaly8.
Sym pt om s/ Physical exam inat ion Tot al
N( 60) %
Sy m pt om s :
Fever 58 97
Pale 48 80
Jaundice 8 13
Diarrhea 25 42
Headache 33 55
Phy sical exam inat ion :
Fever 58 97
Pale 48 80
Jaundice 8 13
Splenom egaly 27 45
H0 33 55
H1 9 15
H2 11 18
H3 7 12
Hepat om egaly 10 17
Source : Sy ahril Pasaribu 6 . An t im a la r ia l D r u gs
Em il Azlin et al in t heir st udy found t hat .
- 35 pat ient s ( falciparum m alaria) had been t reat ed w it h Chloroquine. Plasm odia
falciparum Resist ance t o Chloroquine w ere found in 10 cases ( Grade RI I) , and 1 case
w it h ( Grade RI I I).
- 48 pat ient s ( falciparum m alaria) had been t reat ed w it h Fansidar. Plasm odia falciparum
resist ance t o Fansidar w ere found in 14 cases ( Grade RI I)9.
I n I ndonesia t hese t w o drugs are st ill t he drug of choice in t he t reat m ent cases of falciparum m alaria.
- I ron supplem ent at ion has benefit on m alaria infect ion in endem ic areas w here I ron
deficiency Anem ia ( I DA) is prevalent1 0.
- Vit am in A supplem ent at ion has been show n t o low er t he m orbidit y of m alaria
infect ion in t he Dist rict of Mandailing Nat al, Nort h Sum at era Province1 1.
7 . Con clu sion s
Malaria is st ill a m ain problem in som e dist rict s of Nort h Sum at era Province.
We considered t hat , t w o species out of four species of plasm odia ( falciparum and v iv ax ) t o be nat ural parasit e of m an in Nort h Sum at era Province.
Re fe r e n ce s
1. Faust , Evnest Carroll and Paul Farr Russel, 1965 : Malaria Parasit e; in Clinical Parasit ology , Philadelphia : Lea & Febiger
2. WHO Expert Com m it t ee on Malaria. Tw ent iet h report . Genev a, Sw it zerland,1988: 14- 17 3. Marlet a R, Hariyani et al : Penelit ian Malaria Di Kecam at an Teluk Dalam , Nias,
Sum at era Ut ara, Cerm in Dunia Kedok t eran, 1996; 106 : 5 – 9.
4. Ram pengan TH, Laurent z I R. Peny ak it I nfek si Tropis Pada Anak . Jak art a, EGC, 1997: 185- 204
5. Suhardiono, Depart m ent of Healt h, Nort h Sum at era Province ( Unpublished) : Analisa
Sit uasi Peny akit Malaria 2000 & 2001 Dan Program P2 Malaria Tahun 2002 Di Propinsi Sum at era Ut ara.
6. Roll Back Malaria. Econom ic cost s of m alaria, 2001 – 2010. unit ed Nat ion Decade t o
Roll Back Malaria. Available from URL: ht t p: / / w w w .rbm .w ho.int / cm c_upload/ 0/ 000/ 015/ 363/ RBMI nfosheet _10.ht m
7. BPS St at ist ics of Sum at era Ut ara : Sum at era Ut ara Dalam Angk a.
8. Pasaribu S and Lubis C.P. : The Correlat ion Bet w een Paraset em ia And Spleen Size I n
Children. Wit h Falciparum Malaria; Present ed at 6t h I nt ernat ional Congress of Tropical Pediat rics, Ank ara, Turkey, 26- 30 Sept em ber 2002.
9. Em il Azlin, Bat ubara I HH et al : The efficacy of Chloroquine Com pared t o Fansidar in
Treat ing Falciparum Malaria in Mandailing Nat al; Present ed at Nat ional Congress of
Pediat rics ( KONI KA) XI I I , Bali, I ndonesia, 1 - 4 July 2002.
10. Yulizar, Lubis S, Lubis M, Lubis B, Pasaribu S. The effect of iron supplem ent at ion on m alaria infect ion t reat ed by ant im alarial agent s w it h red blood cell indices param et ers. Present ed at Nat ional Congress of Pediat rics ( KONI KA) XI I I , Bali, I ndonesia, 1- 4 July 2002
