Murad Lesmana

The burden of diarrhoea, shigellosis, and cholera in North Jakarta, Indonesia: findings from 24 months surveillance

BackgroundIn preparation of vaccines trials to estimate protection against shigellosis and cholera we conducted a two-year community-based surveillance study in an impoverished area of North Jakarta which provided updated information on the disease burden in the area.MethodsWe conducted a two-year community-based surveillance study from August 2001 to July 2003 in an impoverished area of North Jakarta to assess the burden of diarrhoea, shigellosis, and cholera. At participating health care providers, a case report form was completed and stool sample collected from cases presenting with diarrhoea.ResultsInfants had the highest incidences of diarrhoea (759/1 000/year) and cholera (4/1 000/year). Diarrhea incidence was significantly higher in boys under 5 years (387/1 000/year) than girls under 5 years (309/1 000/year; p < 0.001). Children aged 1 to 2 years had the highest incidence of shigellosis (32/1 000/year). Shigella flexneri was the most common Shigella species isolated and 73% to 95% of these isolates were resistant to ampicillin, trimethoprim-sulfamethoxazole, chloramphenicol and tetracycline but remain susceptible to nalidixic acid, ciprofloxacin, and ceftriaxone. We found an overall incidence of cholera of 0.5/1 000/year. Cholera was most common in children, with the highest incidence at 4/1 000/year in those less than 1 year of age. Of the 154 V. cholerae O1 isolates, 89 (58%) were of the El Tor Ogawa serotype and 65 (42%) were El Tor Inaba. Thirty-four percent of patients with cholera were intravenously rehydrated and 22% required hospitalization. V. parahaemolyticus infections were detected sporadically but increased from July 2002 onwards.ConclusionDiarrhoea causes a heavy public health burden in Jakarta particularly in young children. The impact of shigellosis is exacerbated by the threat of antimicrobial resistance, whereas that of cholera is aggravated by its severe manifestations.

Spectrum of vibrio species associated with acute diarrhea in North Jakarta, Indonesia

Vibrio spp was isolated from 1024 (21.2%) of 4820 diarrhea patients admitted to a community hospital in North Jakarta from 1996 through 1998. Vibrio cholerae O1 (49.5%) and V. parahaemolyticus (30.1%) comprised the major species isolated, followed by V. cholerae non-O1 (16.9%), and V. fluvialis (9.4%). In 938 (19.4%) patients, Vibrio was found as single isolate. Multiple infections were detected in 86 (1.8%) patients. A small number of V. furnisii, V. metschnikovii, V. mimicus and V. hollisae were also isolated. No V. cholerae O139 was detected. The majority of patients with Vibrio spp. infections were adults between the ages of 20 to 45 years. No Vibrio spp. was isolated from infants <1 year old in this study. In vitro antibiotic susceptibility testing revealed no antibiotic resistance associated with the 507 V. cholerae O1 isolates tested, except for colistin (100%). These data implicate Vibrio spp. as a major cause of diarrhea in this region.

Etiology of Acute, Non-Malaria, Febrile Illnesses in Jayapura, Northeastern Papua, Indonesia

We conducted a prospective, inpatient fever study in malaria-endemic Papua, Indonesia to determine non-malaria fever etiologies. Investigations included malaria blood films, blood culture, paired serologic samples analysis for dengue, Japanese encephalitis, leptospirosis, scrub typhus, murine typhus, and spotted fever group rickettsia. During 1997–2000, 226 patients (127 males and 99 females) 1–80 years of age (median age = 25 years) were enrolled. Positive blood cultures (n = 34, 15%) were obtained for Salmonella Typhi (n = 13), Escherichia coli (n = 8), Streptococcus pneumoniae (n = 6), Staphylococcus aureus (n = 5), Streptococcus pyogenes (n = 1), and Klebsiella pneumoniae (n = 1). Twenty (8.8%) patients were positive for leptospirosis by polymerase chain reaction. Eighty (35.4%) of 226 patients had ≥ 1 positive serology, diagnostic for 15 rickettsial and 9 dengue cases. Acid-fast bacilli–positive sputum was obtained from three patients. Most common confirmed (81 of 226, 35.8%)/suspected diagnoses were typhoid fever (n = 41), pneumonia (n = 29), leptospirosis (n = 28), urinary tract infections (n = 20), rickettsioses (n = 19), dengue (n = 17), and meningitis/encephalitis (n = 15). There were 17 deaths, 7 (46.7%) were caused by meningitis/encephalitis. Multiple positive serologic results and few confirmed diagnoses indicate the need for improved diagnostics.

Vibrio parahaemolyticus associated with cholera-like diarrhea among patients in North Jakarta, Indonesia

A diarrhea study was conducted in North Jakarta, Indonesia from December 1996 through December 1997. Vibrio parahaemolyticus was isolated from 333 (6.1%) of 5442 rectal swab samples collected from patients with cholera-like diarrhea. Vibrio cholerae O1 was isolated from 545 (10.0%) and V. cholerae non-O1 from 183 samples (3.4%), respectively. Patients positive for V. parahaemolyticus were mostly adults between 20 and 40 years of age, with males constituting 62%. A majority (65%) of these patients demonstrated watery diarrhea with a frequency of fewer than 10 episodes per 24 hour. A large number of the patients had abdominal pain (83%) and vomiting (76%) and were non-febrile (90%). The highest isolation rate (9.6%) of V. parahaemolyticus was found during the dry season (June, July) and the lowest (4.5%) in the rainy season (December, January, February). All of the V. parahaemolyticus isolates were hemolytic on human blood agar (positive Kanagawa) but none was urease positive. Disk diffusion antibiotic susceptibility tests performed on the isolates demonstrated resistance to ampicillin (98%), cephalothin (24%), kanamycin (15%), colistin (97%), neomycin (2%) and ceftriaxone (0.3%). All isolates (100%) were sensitive to chloramphenicol, tetracycline, trimethoprim-sulfamethoxazole, gentamicin, and ciprofloxacin.

Surveillance of bacterial pathogens of diarrhea disease in Indonesia

Emerging or reemerging infections due to bacterial disease may be a local, regional or global problem. Bacterial acute gastroenteritis is a potential cause of substantial morbidity in travelers and deployed U.S. military personnel. A surveillance study was conducted over a two-year period in Indonesia among 6760 patients with debilitating diarrheal diseases. Of the 6,760 patients, 587 (9%) of the patient stools were positive for bacteria. The proportions of bacteria isolated from the 587 patients were: Shigella flexneri (39%), Salmonella spp. (26%), Vibrio spp. (17%), S. sonnei (7%), Campylobacter jejuni (4.4%), Salmonella typhi (3%) and S. dysenteriae (2.3%). Shigella flexneri was the most prevalent pathogen isolated, over Vibrio spp. No V. cholerae was isolated in the cities of Pontianak, Padang or Batam in Indonesia. Shigella dysenteriae reemergence was noted in Bali, Kalimantan, Batam and Jakarta after an absence of 15 years. Isolation of a high proportion of S. flexneri, and Vibrio spp. occurred during the rainy months. All bacterial isolates were susceptible to quinolones, with the exception of C. jejuni and Salmonella spp., which were resistant to ciprofloxacin, norfloxacin and nalidixic acid. Our findings highlight the decline of V. cholerae, the rise of S. flexneri and the reemergence of S. dysenteriae in Indonesia. The study also documents the emergence of quinolone-resistant Campylobacter spp. in the Indonesia archipelago.

In Vitro Antibiotic Susceptibility of Neisseria gonorrhoeae in Jakarta, Indonesia

ABSTRACT Antibiotic susceptibilities were determined for 122 Neisseria gonorrheae isolates obtained from 400 sex workers in Jakarta, Indonesia, and susceptibilities to ciprofloxacin, cefuroxime, cefoxitin, cefotaxime, ceftriaxone, chloramphenicol, and spectinomycin were found. All isolates were resistant to tetracycline. A number of the isolates demonstrated decreased susceptibilities to erythromycin (MIC ≥ 1.0 μg/ml), thiamphenicol (MIC ≥ 1.0 μg/ml), kanamycin (MIC ≥ 16.0 μg/ml), penicillin (MIC ≥ 2.0 μg/ml), gentamicin (MIC ≥ 16.0 μg/ml), and norfloxacin (MIC = 0.5 μg/ml). These data showed that certain antibiotics previously used in the treatment of gonorrhea are no longer effective.

Prevalence of enterotoxigenic Escherichia coli (ETEC) in hospitalized acute diarrhea patients in Denpasar, Bali, Indonesia

The relationship between enterotoxigenic Escherichia coli (ETEC) and hospitalized patients with acute diarrhea was examined in a study conducted in two hospitals from June 2000 to May 2001 in Denpasar, Bali, Indonesia. A total of 489 hospitalized patients with acute diarrhea were enrolled, and their rectal swabs were screened for enteric bacterial pathogens. Toxins, colonization factor antigens (CFAs), in vitro antimicrobial susceptibility and seasonal distribution patterns associated with ETEC were ascertained. The diagnosis of ETEC infection and CFAs association were performed with GM-1 ELISA and Dot blot immunoassays. Enterotoxigenic Escherichia coli was isolated from the rectal swabs of 14.9% of the patients. The distribution of toxins among the ETEC strains found was ST in 51 (69.9%), while LT and ST/LT were found in 28.8% and 1.3% respectively. The highest isolation rate for ETEC was found among children between the ages of 1 and 15 years. Colonization factor antigens were identified in 28.8% of the ETEC strains. A high prevalence of CFA was found among the rectal swabs of patients with ST isolates. High frequency of resistance to ampicillin, trimethoprim/sulfamethoxazole, chloramphenicol, tetracycline and cephalothin was displayed among the ETEC strains. All ETEC strains were susceptible to norfloxacin, ciprofloxacin and nalidixic acid. The results of this study document the prevalence of ETEC in hospitalized patients with acute diarrhea in Denpasar, Bali, Indonesia. Data generated in this study depicts the prevalence of ETEC diarrhea and CFA types among diarrhea patients in the tourist city of Denpasar, Bali, Indonesia.

Growth Inhibition of Enteric Pathogens by Zinc Sulfate: An in vitro Study

Objective: To determine the inhibition effect of zinc sulfate on isolates of enteric bacteria. Materials and Methods: Mueller-Hinton agar containing different concentrations of zinc sulfate was prepared. Isolates used in this study were obtained from local clinics. They were Salmonella typhi, Salmonella groups A, B, C, D and E, Escherichia coli, Enterobacter, Shigella and Vibrio cholerae. Overnight cultures of test organisms in brain-heart infusion broth were adjusted to 0.5 McFarland standard turbidity by adding normal saline with 1 µl of each adjusted broth culture inoculated onto zinc sulfate agar plates. The plates were incubated for 18–20 h at 37°C. The inhibition concentration was recorded as the lowest concentration of zinc sulfate that completely inhibited growth. Results: All enteric pathogens tested were inhibited by zinc sulfate. Of the isolates, S. typhi was most sensitive since 20% of the strains were inhibited by zinc sulfate of 0.8 mg/ml. Salmonella paratyphi A was inhibited at 1.2 mg/ml. Other Salmonella spp. were inhibited at concentrations between 1.4 and 2.0 mg/ml. V. cholerae O1 and Shigella flexneri demonstrated a similar pattern of inhibition as S. paratyphi A. A higher concentration of zinc sulfate (1.6 mg/ml) was required to completely inhibit Shigella sonnei. Conclusion: The findings indicate that zinc sulfate has an antimicrobial effect on enteric pathogens and may contribute to the treatment of diarrhea.

USE OF MODIFIED CAMP TEST FOR PRELIMINARY NONSEROLOGIC IDENTIFICATION OF VIBRIO CHOLERAE IN STOOL SPECIMENS

Serological surveys of pigs (Sus scrofa) and bats (Chiroptera) were conducted in Sin tang over 3 subdistricts (Kayanhulu, Kayanhilir, Kotabaru) during the period of 17 July to 2 August 1994. Blood samples were collected fron 68 pigs and 157 bats and tested for JEV antibody. Antibody to JEV were found in 39 (57%) pig sera and 24 (15.3%) bat sera using a hemagglutination inhibition (HI) test. This study gives more information on the geographic and host distribution of JEV in Indonesia, and increased knowledge about potential risk of JEV to public health.

DETECTION OF SYNERGISTIC HEMOLYSIS BETWEEN VIBRIO CHOLERAE NON-O1 AND STAPHYLOCOCCAL BETA-LYSIN WITH MODIFIED CAMP TEST

A treatment trial of artesunate for uncomplicated falciparum malaria cases was conducted at ITCI Hospital, Balikpapan, East Kalimantan, Indonesia, in November 1992 - Januari 1993. The objectives of this study were to assess the efficacy and safety of artesunate. Thirty eight falcipamm malaria patients who had been selected according to criteria for the in vivo sensitivity test were treated orally with 100 mg artesunate 12 hourly on DO and followed 50 mg 12 hourly on Dl-4. All patients were hospitalized until declared cured clinically and parasitologicalty. The most prevalent clinical symptoms of these malaria patients were fever (84,2%), headache (81,6%), nausea (73,7%) and splenomegaly (71,0%o). The cure rates of artesunate were 100% (38/38 and 28/28) on D7 and D14, but on D21 and D28 there were 88,2% (15/17) and 75% (6/8) because of the presence of late Rl cases. The mean fever clearance time (FCT) and parasite clearance time (PCT) were as follows 15,1 1,8 h and 32,1 3,0 h (D7), 14,1 2,2 h and 33,3 3,8 h (D14), 15,7 3,0 h and 37,6 5,6 h (D21), 14,0 4,6 h and 32,0 5,9 h (D28) respectively. No side effect was found clinically and on laboratory examinations. Artesunate is effective and safe for treatment of uncomplicated falciparum malaria until D14 in a multidrug resistant area. A sequential combination of artesunate and other antimalarial drugs should be studied to achieve a radical cure.