Malaria In North Sumatera Province The Situation and Characteristics

MALARIA IN NORTH SUMATERA PROVINCE THE SITUATION AND
CHARACTERISTICS
CHAIRUDDIN P. LUBIS AND SYAHRIL PASARIBU
Department of Child Health
Medical School, University of Sumatera Utara
Medan, Indonesia
1. Background
Malaria is a chronic, invalid-producing disease which does not directly kill more than
1 or 2 per-cent of its victims, although it is often a major cause of infant mortality.
The disease results in increasing the number of deaths from other causes and it
reduces life expectancy, except in epidemic times, it is insidious rather than
dramatic. Nevertheless over centuries, malaria has had a profound influence on
thousands of communities throughout the world. But there is ample testimony to the
fact that malaria has been one of the great scourges of humanity because of its
deleterious stunting of physical and mental development, its notorious restricting of
social and national growth, and its blighting of agriculture, commerce and industry1.
At present, about 100 countries or territories in the world are considered malarious,
almost half of which are in Africa, south of the Sahara. Although this number is
considerably less than it was in the mid-1950s (140 countries or territories), more
than 2400 million of the world’s population are still at risk.
The incidence of malaria worldwide is estimated to be 300 – 500 million clinical cases

each year, with about 90% of these occurring in Africa, south of the Sahara – mostly
caused by P.falciparum. Malaria is thought to kill between 1.1. and 2.7 million people
worldwide each year, of whom about 1 million are children under the age of 5 years
in Africa, south of the Sahara. These childhood deaths, resulting mainly from
cerebral malaria and anemia, constitute nearly 25% of child mortality in Africa.
Fatality rates of 10 – 30% have been reported among children referred to hospital
with severe malaria, although these rates are even higher in rural and remote areas
where patients have restricted access to adequate treatment. Deaths from malaria in
countries outside Africa, south of the Sahara, occur principally in non-immune people
who become infected with P.falciparum in areas where diagnosis and treatment are
not available2.
In Indonesia malaria is still a major public health problem, especially out of Java and
Bali3. The mortality of malaria in Java and Bali were 1-2 person per 1000 population
in 1983, and 10 fold in other islands of Indonesia4.
In North Sumatera Province, malaria is not affecting the entire population, because
cases are concentrated in some specific districts. Cases seen in other districts are
imported cases, who have visited malaria areas.
In North Sumatera Province the Annual Malariae Incidence (AMI) in the year 2000 is
6.03%, and in the year 2001 is 3.42%5.
Resistance of P.falciparum to chloroquine is now common in practically all malariaendemic countries in the world, especially in east Africa, thus posing increasing

problems for the provision of suitable treatment (Figure 2).

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Resistance to sulfadoxine/pyrimethamine, the main alternative to chloroquine. Is
widespread in south-east Asia and south America. Mefloquine resistance is now
common in the border areas of Thailand with Cambodia and Myanmar. Resistance of
P.vivax to chloroquine has now been reported from Indonesia (Irian Jaya), Myanmar,

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Papua New Guinea and Vanuatu. Cross-resistance to amodiaquine sometimes
occurs2.
Malaria has significant measurable direct and indirect costs, and has recently been
shown to be a major constraint to economic development. For developing economies
this has meant that the gap in prosperity between countries with malaria and

countries without malaria has become wider every single year.
Annual economic growth in countries with high malaria transmission has historically
been lower than in countries without malaria. Economists believe that malaria is
responsible for a ‘growth penalty’ of up to 1.3% per year in some African countries.
When compounded over the years, this penalty leads to substantial differences in
GDP between countries with and without malaria and severely restrains the economic
growth of the entire region.
The direct costs of malaria include a combination of personal and public expenditures
on both prevention and treatment of the disease. Personal expenditures include
individual or family spending on insecticide treated mosquito nets (ITNs), doctors’
fees, anti-malarial drugs, transport to health facilities, support for the patient and
sometimes an accompanying family member during hospital stays. Public
expenditures include spending by government on maintaining health facilities and
health care infrastructure, publicly managed vector control, education and research.
In some countries with a heavy malaria burden, the disease may account for as
much as 40% of public health expenditure, 30 – 50% of patient admissions, and up
to 50% of outpatient visits.
The indirect costs of malaria include lost productivity or income associated with
illness or death. This might be expressed as the cost of lost workdays or absenteeism
from formal employment and the value of unpaid work done in the home by both

men and women. In the case of death, the indirect cost includes the discounted
future lifetime earnings of those who die6.
2. Profile of North Sumatera
Area
:
Geographical Location
Border on the North
:
Border on the South
:
Border on the East
:
Border on the West
:
Climate;
June – September
:
November – March
:
District

:
Municipality
:
Number of Villages
:
Population (Census) 2000
:
Population Growth 1990 – 2000
:
Male
:
Female
0-4 years
:
Rural Population
:
Urban Population
:
Households
:

Household Average Size
:
Source : BPS Statistics of Sumatera Utara

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71.680 km2
Nanggroe Aceh Darussalam
Riau and West Sumatera
Strait of Malaca/Malaysia
Indian Ocean
Dry Season
Rainy Season
13 Districts
7 Municipal cities
5.238
11.722.397
1.20%
49.98%
:

50.02%
11,49
56.89%
43.11%
2.755.606
4.25 persons
Province7

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3. Distribution of Malaria
Regarding of malaria risk, North Sumatera Province is divided into 2 groups;
Endemic Area and Non-Endemic Area. Districts including in the group of Endemic
Area are Mandailing Natal; Tapanuli Selatan; Tapanuli Tengah; Asahan; Labuhan
Batu and Deli Serdang.
Monthly Report of Malaria Cases
in North Sumatera Province
Year 2000
No.


Districts/Municipality

Total No of Cases

No of Death

1

Medan*

-

-

2

Binjai

0


0

3

Tebing Tinggi

0

0

4

Tanjung Balai

440

0

5


Sibolga**

630

0

6

Pematang Siantar

0

0

7

Deli Serdang

3166


0

8

Langkat*

-

-

9

Asahan

9619

2

10

Labuhan Batu**

1342

15

11

Simalungun

2109

0

12

Tapanuli Utara**

261

0

13

Toba Samosir

99

0

14

Tapanuli Tengah

5227

0

15

Padang Sidempuan/ **

16

Tapanuli Selatan

6038

0

17

Madina

14773

3

18

Karo**

1090

0

19

Dairi**

267

0

20

Nias*

-

-

Total
45061
Source : Department of Health North Sumatera Province
* : No significant report yet
** : The report obtained only for a few months

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Monthly Report of Malaria Cases
in North Sumatera Province
Year 2001

No.

Districts/

Total

Municipality

No of Cases

No of Death

1

Medan*

-

-

2

Binjai**

0

0

3

Tebing Tinggi**

0

0

4

Tanjung Balai**

297

0

5

Sibolga**

585

0

6

Pematang Siantar**

0

0

7

Deli Serdang**

1306

0

8

Langkat*

0

0

9

Asahan**

4931

0

10

Labuhan Batu

5437

0

11

Simalungun*

0

0

12

Tapanuli Utara**

240

0

13

Toba Samosir**

52

0

14

Tapanuli Tengah**

2210

0

15

Padang Sidempuan/ *

5319

0

16

Tapanuli Selatan

17

Madina

10765

0

18

Karo

1227

0

19

Dairi*

0

0

20

Nias*

-

-

Total
32369
Source : Department of Health North Sumatera Province

0

* : No significant report yet
** : The report obtained only for a few months

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4. The Species of Malaria
Since 1997 until 2001, the Department of Health has done a survey of malaria in some
villages in six districts of North Sumatera Province. The number of population was 6.394
included in this survey. Blood smear examination showed that malaria positive was found
in 1.382 cases, the species of plasmodia being falciparum and vivax5.
No of
Population
6,394

The Species of Malaria in North Sumatera Province
Plasmodia
Species of Plasmodia
Positive
Falciparum
Vivax
1,382

903

Mixed

458

21

Source : Department of Health North Sumatera Province
During April 2001, Pasaribu conducted a study of malaria in 5 villages in District of
Mandailing Natal. 152 patients of malaria; 60 cases were malaria falciparum; 83 vivax
malaria and 9 of mixed infection8.
No of Cases Plasmodia
Positive
152

The Species of Malaria
Species of Plasmodia
Falciparum
Vivax
60

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83

Mixed
9

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From these data we consider that only two out of four species of plasmodia is of natural
parasites of man in North Sumatera Province that is falciparum and vivax. There is no
report about ovale and malariae species in this area.
5. Clinical manifestation of malaria patients
From history, the most clinical symptoms were fever (97%), pale (80%), headache (55%),
diarrhea (42%), and jaundice (13%) respectively. On physical examination we found that
27 patients had splenomegaly8.
Symptoms/Physical examination
Symptoms :
Fever
Pale
Jaundice
Diarrhea
Headache
Physical examination :
Fever
Pale
Jaundice
Splenomegaly
H0
H1
H2
H3
Hepatomegaly
Source : Syahril Pasaribu

Total
N(60)

%

58
48
8
25
33

97
80
13
42
55

58
48
8

97
80
13

27

45
33
9
11
7
10

55
15
18
12
17

6. Antimalarial Drugs
Emil Azlin et al in their study found that.
35 patients (falciparum malaria) had been treated with Chloroquine. Plasmodia
falciparum Resistance to Chloroquine were found in 10 cases (Grade RII), and 1 case
with (Grade RIII).
- 48 patients (falciparum malaria) had been treated with Fansidar. Plasmodia falciparum
resistance to Fansidar were found in 14 cases (Grade RII)9.
In Indonesia these two drugs are still the drug of choice in the treatment cases of
falciparum malaria.
- Iron supplementation has benefit on malaria infection in endemic areas where Iron
deficiency Anemia (IDA) is prevalent10.
- Vitamin A supplementation has been shown to lower the morbidity of malaria
infection in the District of Mandailing Natal, North Sumatera Province11.
7. Conclusions
Malaria is still a main problem in some districts of North Sumatera Province.
We considered that, two species out of four species of plasmodia (falciparum and vivax) to
be natural parasite of man in North Sumatera Province.
Eventhough the resistance to chloroquine and fonsidar was found in some cases;
chloroquine and fansidar are still a drug of choice in the treatment of falciparum malaria.

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References
1. Faust, Evnest Carroll and Paul Farr Russel, 1965 : Malaria Parasite; in Clinical
Parasitology, Philadelphia : Lea & Febiger
2. WHO Expert Committee on Malaria. Twentieth report. Geneva, Switzerland,1988:14-17
3. Marleta R, Hariyani et al : Penelitian Malaria Di Kecamatan Teluk Dalam, Nias,
Sumatera Utara, Cermin Dunia Kedokteran, 1996; 106 : 5 – 9.
4. Rampengan TH, Laurentz IR. Penyakit Infeksi Tropis Pada Anak. Jakarta, EGC,
1997:185-204
5. Suhardiono, Department of Health, North Sumatera Province (Unpublished) : Analisa
Situasi Penyakit Malaria 2000 & 2001 Dan Program P2 Malaria Tahun 2002 Di Propinsi
Sumatera Utara.
6. Roll Back Malaria. Economic costs of malaria, 2001 – 2010. united Nation Decade to
Roll
Back
Malaria.
Available
from
URL:
http://www.rbm.who.int/cmc_upload/0/000/015/363/RBMInfosheet_10.htm
7. BPS Statistics of Sumatera Utara : Sumatera Utara Dalam Angka.
8. Pasaribu S and Lubis C.P. : The Correlation Between Parasetemia And Spleen Size In
Children. With Falciparum Malaria; Presented at 6th International Congress of Tropical
Pediatrics, Ankara, Turkey, 26-30 September 2002.
9. Emil Azlin, Batubara IHH et al : The efficacy of Chloroquine Compared to Fansidar in
Treating Falciparum Malaria in Mandailing Natal; Presented at National Congress of
Pediatrics (KONIKA) XIII, Bali, Indonesia, 1 - 4 July 2002.
10. Yulizar, Lubis S, Lubis M, Lubis B, Pasaribu S. The effect of iron supplementation on
malaria infection treated by antimalarial agents with red blood cell indices parameters.
Presented at National Congress of Pediatrics (KONIKA) XIII, Bali, Indonesia, 1- 4 July
2002
11. Adilida, Lubis S, Lubis B, Lubis M, Sembiring T, Pasaribu S. Effect of vitamin A
supplementation on morbidity due to plasmodium falciparum : an 8 months follow up
report. Presented at National Congress of Pediatrics (KONIKA) XIII, Bali, Indonesia, 1 –
4 July 2002.

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