(BBL, Sensi-Disc; Becton Dickinson and Company, Sparks,. MD) were used in the test: ..... pud, Narain Punjabi, James R. Campbell, William K. Alexander, H. James Beecham III ... Chakraborty J, Henry F, Ronsmans C, 1992. Antimicrobial.
Am. J. Trop. Med. Hyg., 68(6), 2003, pp. 666–670 Copyright © 2003 by The American Society of Tropical Medicine and Hygiene
ANTIMICROBIAL RESISTANCE OF BACTERIAL PATHOGENS ASSOCIATED WITH DIARRHEAL PATIENTS IN INDONESIA PERISKA TJANIADI, MURAD LESMANA, DECY SUBEKTI, NUNUNG MACHPUD, SHINTA KOMALARINI, WASIS SANTOSO, CYRUS H. SIMANJUNTAK, NARAIN PUNJABI, JAMES R. CAMPBELL, WILLIAM K. ALEXANDER, H. JAMES BEECHAM III, ANDREW L. CORWIN, AND BUHARI A. OYOFO United States Naval Medical Research Unit No. 2, Jakarta, Indonesia; Sumber Waras Hospital, Jakarta, Indonesia; Friendship Hospital, Jakarta, Indonesia; National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia; Medical Faculty, Trisakti University, Jakarta, Indonesia
Abstract. The antimicrobial susceptibility patterns for 2,812 bacterial pathogens isolated from diarrheal patients admitted to hospitals in several provinces in the cities of Jakarta, Padang, Medan, Denpasar, Pontianak, Makassar, and Batam, Indonesia were analyzed from 1995 to 2001 to determine their changing trends in response to eight antibiotics: ampicillin, trimethoprim-sulfamethoxazole, chloramphenicol, tetracycline, cephalothin, ceftriaxone, norfloxacin, and ciprofloxacin. Vibrio cholerae O1 (37.1%) was the pathogen most frequently detected, followed by Shigella spp. (27.3%), Salmonella spp. (17.7%), V. parahaemolyticus (7.3%), Salmonella typhi (3.9%), Campylobacter jejuni (3.6%), V. cholerae non-O1 (2.4%), and Salmonella paratyphi A (0.7%). Of the 767 Shigella spp. isolated, 82.8% were S. flexneri, 15.0% were S. sonnei, and 2.2% were S. dysenteriae (2.2%). The re-emergence of Shigella dysenteriae was noted in 1998, after an absence of 15 years. Shigella spp. were resistant to ampicillin, trimethoprim-sulfamethoxazole, chloramphenicol, and tetracycline. Salmonella typhi and Salmonella paratyphi A were susceptible to all antibiotics tested, while Salmonella spp. showed various resistance patterns according to species grouping. A small number of V. cholerae O1 were resistant to ampicillin, trimethoprim-sulfamethoxazole, chloramphenicol, and tetracycline; however, they were still sensitive to ceftriaxon, norfloxacin, and ciprofloxacin. Similar results were shown for V. cholerae non-O1. Campylobacter jejuni showed an increased frequency of resistance to ceftriaxone, norfloxacin, and ciprofloxacin, but was susceptible to erythromycin. This study shows that except for C. jejuni and V. parahaemolyticus, which appeared to be resistant to ciprofloxacin, the majority of the enteric pathogens tested were still susceptible to fluoroquinolones. INTRODUCTION
Resistance (R) factor plasmids are extrachromosomal DNA elements of bacteria that confer drug resistance on their host bacteria. They can transfer themselves to other bacteria by conjugation and by phage-mediated transduction. They can also integrate into the host chromosome. These factors can be transferred not only to Enterobacteriaceae, but also to a variety of gram-negative bacilli such as Pseudomonas, Vibrio cholerae, and others. In fact, highly virulent strains of bacteria carrying R factors can cause infections in humans and animals. An important point with R factors is that many of them carry multiple drug resistance genes.12 In Indonesia, most hospitals and clinics treat diarrhealinfected patients with antibiotics prior to receiving definitive laboratory results. For treatment of Campylobacter infections in Indonesia, erythromycin is most often used. For infections with Salmonella spp. and Shigella spp., trimethoprimsulfamethoxazole is used, while for cholera, tetracycline is used. Fluoroquinolones are not commonly used for the treatment of diarrheal infections because they are expensive. As a result of these concerns, this study sought to explore developing trends and patterns of resistance to eight antimicrobial agents used for the treatment of patients with enteric bacteria related diarrhea in Indonesia.
Antimicrobial resistance in enteric pathogens is of great importance in the developing world, where the rate of diarrheal diseases is highest. The progressive increase in antimicrobial resistance among enteric pathogens in developing countries is becoming a critical area of concern. The acute diarrheal diseases for which antimicrobial therapy is clearly effective include shigellosis, cholera, and campylobacteriosis. However, for campylobacteriosis, the diagnosis is usually too late for antimicrobial therapy to be effective.1,2 Among the bacteria causing diarrheal diseases, Salmonella spp. continue to be a major public health problem. Although most Salmonella infections are self-limiting, serious sequelae, including systemic infection and death, can occur.3,4 In addition, since the 1960s various Salmonella spp. resistant to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole have been reported with increasing frequency through out the world.5 Strains of C. jejuni have also been reported as resistant to ampicillin, carbenicillin, clindamycin, gentamicin, tobramycin, streptomycin, and metronidazole.6 The emergence of Campylobacter spp. that are resistant to ciprofloxacin has been reported in Thailand.7,8 A similar emergence in Spain, where the isolation rate of ciprofloxacin-resistant Campylobacter increased from 0% in 1987 to 30% in 1991.9 In Spain and elsewhere in Europe, the rate of Campylobacter resistance to fluoroquinolones appears to be increasing because fluoroquinolones are used in both human and veterinary medicine.9 Over the past several decades, strains of Shigella spp. have progressively become resistant to most of the widely used and inexpensive antimicrobials.10 The re-emergence of Shigella dysenteriae after a 15-year absence was recently observed in Indonesia, and this species was shown to be resistant to ampicillin, trimethoprim-sulfamethoxazole, and tetracycline.11
MATERIALS AND METHODS Sample collection and bacteriologic isolation. A total of 2,812 strains of pathogenic bacteria were isolated from the stool samples of patients presenting with diarrhea from 1995 to 2001. There were 21,763 rectal swab samples collected from 11,823 males and 9,940 females. The median age of the patients was three years (age range ⳱ 1 month to 96 years). Fifty-four percent of the samples were collected from young children (0–4 years old). Rectal swab specimens were collected on the day of admission from patients admitted to the
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RESULTS
following hospitals: Dr. Pirngadi Hospital in Medan, Sumatra, Dr. M. Jamil Hospital in Padang, Otorita Hospital in Batam, Sumber Waras Hospital and Persahabatan Hospital in Jakarta, Sanglah and Wangaya Hospital in Denpasar, Bali, Dr. Sudarso Hospital in Pontianak, Kalimantan, and Labuang Baji Hospital in Makassar, Sulawesi. Diarrhea was defined as three or more loose stools that assumed the shape of a container. Two rectal swabs were obtained from each patient, placed in a Cary-Blair transport medium (BBL, Cockeysville, MD) and transported within 24 hours to the U. S. Naval Medical Research Unit No. laboratory for analysis. Prior to reaching this laboratory, the Cary-Blair media were kept in a refrigerator and transported in a chilled cooler. Upon arrival, one swab was directly cultured onto MacConkey (MC) agar, Salmonella-Shigella (SS) agar, thiosulfate-citrate-bile-sucrose medium (TCBS), and Campylobacter blood agar (CAB) for the isolation of Salmonella, Shigella, V. cholerae and Campylobacter, respectively. This swab was then enriched in alkaline peptone water (APW) to recover V. cholerae. The second swab was put in a mannitol selenite broth (MSB) to enhance the isolation of Salmonella spp. The enrichment broth for Salmonella was subcultured onto SS agar. The APW enrichment broth for V. cholerae was subcultured onto TCBS agar. The plates were incubated at 35-37°C for 18 hours, except for CAB, which was incubated at 42°C for 48–72 hours in an atmosphere of 5% oxygen and 10% carbon dioxide in an aerobic jar with Campy Pak Plus (BBL). Identification was performed using conventional bacteriologic technical methods13 and confirmed by serology using appropriate antiserum (Difco, Detroit, MI). Isolates of V. cholerae non-O were tested by the CAMP method14 and with O139 antiserum. Antimicrobial susceptibility testing. Antibiotic susceptibility testing was performed by the disk diffusion method using guidelines established by the National Committee for Clinical Laboratory Standards (NCCLS).15 For antibiotics for which NCCLS has no defined methods or criteria for susceptibility or resistance, those described in previous reports were used.16–18 A total of eight selected antibiotic disks (BBL, Sensi-Disc; Becton Dickinson and Company, Sparks, MD) were used in the test: ampicillin, trimethoprimsulfamethoxazole, chloramphenicol, tetracycline, cephalothin, ceftriaxone, norfloxacin, and ciprofloxacin. Results were recorded as either sensitive or resistant. The organisms used for quality control were Staphylococcus aureus (ATCC 25923; American Type Culture Collection [ATCC], Manassas, VA) and Escherichia coli (ATCC 25922).
Vibrio cholerae non-O1, V. cholerae O1, and Shigella dysenteriae demonstrated a lower frequency of resistance to ampicillin compared with S. flexneri and V. parahaemolyticus. However, the number of isolates of S. dysenteriae, V. parahaemolyticus, and V. cholerae non-O1 that were resistant to trimethoprim-sulfamethoxazole was lower than that of S. sonnei and C. jejuni. Vibrio cholerae O1 was the predominant pathogen isolated. Overall, there were 1,044 strains of V. cholerae O1 and 68 strains of V. cholerae non-O1. As shown in Table 1, from 1995 to 1999 strains of Vibrio cholerae O1 were 100% susceptible to trimethoprim-sulfamethoxazole and chloramphenicol, but in the years 2000 and 2001, 4% and 1% of the strains, respectively, were resistant to trimethoprim-sulfamethoxazole. Similar resistance patterns were shown with chloramphenicol. Tetracycline resistance increased from 2% in 1998 to 4% in 2001 (P > 0.05). The antibiotic resistance pattern of V. cholerae non-O1 did not differ greatly from 1995 through 2000. However, in 2001, V. cholerae non-O1 demonstrated resistance to all antibiotics normally used in Indonesia for the treatment of diarrhea, which included ampicillin, trimethoprim-sulfamethoxazole, chloramphenicol, and tetracycline. Although the frequency of the resistant isolates was less than 50% (except in 1996 when 60% of V. cholerae non-O1 were resistant to trimethoprimsulfamethoxazole), there was a tendency toward an increase in the number of antibiotics to which the strains were resistant. All strains of Vibrio cholerae non-O1 were non-O139, and no V. cholerae O139 was found in Indonesia. All 204 V. parahaemolyticus strains tested showed increased resistance to ampicillin and cephalotin. Resistance to tetracycline and chloramphenicol was found in 3–15% of the isolates. Vibrio parahaemolyticus was still highly susceptible to the other antibiotics tested (Table 2). Vibrio parahaemolyticus also began to show resistance to ceftriaxone and ciprofloxacin in 2001. Shigella spp. accounted for 27.3% of the total bacterial pathogens isolated. The distribution of the 767 isolated Shigella spp. was as follows: 635 (82.8%) were S. flexneri, 115 (15.0%) were S. sonnei, and 17 (2.2%) were S. dysenteriae. No strain of S. boydii was isolated. Shigella flexneri and S. sonnei shared a similar susceptibility profile for most of the antibiotics tested (Table 3). The most frequent patterns of resistance were exhibited towards ampicillin, trimethoprimsulfamethoxazole, chloramphenicol, and tetracycline. The resistance pattern of S. flexneri to ampicillin appeared similar
TABLE 1 Percentage of antibiotic resistance in Vibrio cholerae O1 and V. cholerae non-O1 in Indonesia* V. cholerae O1
V. cholerae non-O1
Drug
1995 (248)
1996 (98)
1997 (252)
1998 (257)
1999 (36)
2000 (23)
2001 (130)
1995 (12)
1996 (5)
1997 (18)
1998 (12)
1999 (7)
2000 (7)
2001 (7)
AM SXT C TE CF CRO NOR CIP
1 0 0 0 0 0 0 0
1 0 0 1 0 0 0 0
3 0 0 0 1 0 0 0
4 0 0 2 2 0 0 0
0 0 0 0 0 0 0 0
4 4 4 4 0 0 0 0
10 1 3 4 10 0 0 0
33 33 0 0 0 0 0 0
0 60 20 0 0 0 0 0
22 0 6 11 28 0 0 0
42 0 8 8 17 0 0 0
29 43 0 14 0 0 0 0
29 14 0 0 14 0 0 0
14 14 14 29 14 0 0 0
* Values in parentheses are the number of isolates. AM ⳱ ampicillin; SXT ⳱ trimethoprim/sulfamethoxazole; C ⳱ chloramphenicol; TE ⳱ tetracycline; CF ⳱ cephalothin; CRO ⳱ ceftriazone; NOR ⳱ norfloxacin; CIP ⳱ ciprofloxacin.
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roquinolones with the exception of Salmonella group B, which was resistant to both fluoroquinolones (ciprofloxacin, norfloxacin) tested. No strains of S. typhi were resistant to nalidixic acid.
TABLE 2 Percentage of antibiotic resistance in Vibrio parahaemolyticus in Indonesia* Drug
1995 (9)
1996 (22)
1997 (50)
1998 (41)
1999 (33)
2000 (14)
2001 (35)
AM SXT C TE CF CRO NOR CIP
67 0 0 0 0 0 0 0
95 0 0 0 23 0 0 0
94 0 0 0 86 0 0 0
83 0 0 0 69 0 0 0
100 0 3 3 93 0 0 0
79 0 0 7 50 0 0 0
100 0 15 9 94 14 0 11
DISCUSSION Multiple antibiotic resistance in bacterial pathogens is now a common phenomenon in developing countries, including Southeast Asia. This circumstance is most likely related to the frequent use of over-the-counter drugs without proper or no medical supervision.1 Our study documents the trend of multi-resistant bacteria associated with diarrheal disease in Indonesia over a sevenyear period. In Indonesia, tetracycline had been the drug of choice for cholera treatment. In 1996, 1% of V. cholerae were resistant to tetracycline and in 2001, 4% were resistant to tetracycline. In this study, the emergence of V. cholerae resistance to norfloxacin, trimethoprim-sulfamethoxazole, and tetracycline was observed (Table 1). Trimethoprimsulfamethoxazole is used as the second drug of choice in situations where V. cholerae is found resistant to tetracycline. The antibiotic susceptibility pattern of V. parahaemolyticus was similar to that previously reported.17 Trimethoprimsulfamethoxazole appears to be the most effective drug for treatment of this type of infection (Table 2). Shigella flexneri was the predominant species isolated among Shigella spp. during this study, followed by S. sonnei and S. dysenteriae. This finding is consistent with other reports from developing countries such as India,19 Bangladesh,10 Brazil,20 Tanzania,21 Egypt,22 and Thailand.7 Shigella flexneri showed a high degree of resistance to most of the commonly used antibiotics, such as ampicillin, trimethoprimsulfamethoxazole, chloramphenicol, and tetracycline (Table 3). A rapid increase in the resistance of S. flexneri to trimethoprim-sulfamethoxazole has been noted from 52% in 1997 to 80% in 2001 (P < 0.001). This may be due to inappropriate use of these drugs.1 Since 1995, Shigella spp. have been shown to be resistant (> 90%) to trimethoprim-sulfamethoxazole in Thailand.7 Antibiotic resistance among strains of C. jejuni, specifically to ciprofloxacin, was observed (Table 4). In this study, many isolates of C. jejuni were resistant to ampicillin, trimethoprimsulfamethoxazole, tetracycline, cephalothin, ceftriaxone, and fluoroquinolones. Similar patterns of resistance have been
* Values in parentheses are the number of isolates. AM ⳱ ampicillin; SXT ⳱ trimethoprim/sulfamethoxazole; C ⳱ chloramphenicol; TE ⳱ tetracycline; CF ⳱ cephalothin; CRO ⳱ ceftriazone; NOR ⳱ norfloxacin; CIP ⳱ ciprofloxacin.
from 1995 to 2001, except in 1996, in which two strains showed 100% resistance to the antibiotic. There was a tremendous increase in number of resistant strains to cephalotin, increasing from 0% in 1995 to 31% in 2001. Shigella flexneri and S. sonnei isolates were susceptible to ceftriaxone, norfloxacin, and ciprofloxacin (Table 3). Between 1998 and 2001, 17 strains of S. dysenteriae were isolated. Isolates of S. dysenteriae were resistant to ampicillin, trimethoprimsulfamethoxazole, chloramphenicol, tetracycline, and cephalothin (Table 3). Campylobacter infection accounted for 3.6% of the diarrhea episodes. Four strains of C. jejuni were isolated in 1995 and 1996 (Table 4). Until 1997, all C. jejuni isolates were sensitive to chloramphenicol, ciprofloxacin, and erythromycin. In 1998 and 1999, a small number (3–5%) demonstrated resistance to chloramphenicol, but 22–43% developed resistance to ciprofloxacin since 1998. Although the trend toward resistance to multiple antibiotics by Campylobacter spp. continued, no strains of C. jejuni were found resistant to erythromycin. A total of 630 strains of Salmonella spp. were isolated and tested. The distribution of the Salmonella isolates was as follows: 111 S. typhi, 21 S. paratyphi A, 141 Salmonella group B, 106 Salmonella group C, 93 Salmonella group D, 141 Salmonella group E, and 17 of S. enteritidis (not group A, B, C, D, or E). Neither S. typhi nor S. paratyphi A were resistant to a single antibiotic tested, while some isolates of Salmonella group B, C, D, and E and S. enteritidis were resistant to most of the antibiotics tested. All isolates were susceptible to fluo-
TABLE 3 Percentage of antibiotic resistance in Shigella spp. in Indonesia* S. flexneri
S. sonnei
S. dysenteriae
Drug
1995 (10)
1996 (2)
1997 (36)
1998 (71)
1999 (166)
2000 (164)
2001 (186)
1995 (2)
1996 (0)
1997 (11)
1998 (5)
1999 (22)
2000 (34)
2001 (41)
1995 (0)
1996 (0)
1997 (0)
1998 (6)
1999 (8)
2000 (2)
2001 (1)
AM SXT C TE CF CRO NOR CIP
80 0 88 83 0 0 0 0
100 50 100 100 0 0 0 0
81 52 75 89 0 0 0 0
90 53 88 96 4 0 0 0
87 54 84 93 21 0 0 0
91 74 76 96 5 0 0 0
90 80 83 94 31 0 0 0
50 50 50 83 0 0 0 0
– – – – – – – –
9 91 0 100 0 0 0 0
20 80 20 80 0 0 0 0
32 82 32 96 0 0 0 0
41 59 32 88 0 0 0 0
27 76 17 83 37 0 0 0
– – – – – – – –
– – – – – – – –
– – – – – – – –
17 17 0 0 17 0 0 0
50 63 13 50 38 0 0 0
0 50 0 50 0 0 0 0
100 100 100 100 100 0 0 0
* Values in parentheses are the number of isolates. AM ⳱ ampicillin; SXT ⳱ trimethoprim/sulfamethoxazole; C ⳱ chloramphenicol; TE ⳱ tetracycline; CF ⳱ cephalothin; CRO ⳱ ceftriazone; NOR ⳱ norfloxacin; CIP ⳱ ciprofloxacin. – ⳱ no isolate obtained.
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BACTERIAL ANTIBIOTIC RESISTANCE IN INDONESIA
TABLE 4 Percentage of antibiotic resistance in C. jejuni strains in Indonesia* Drug
1995 (2)
1996 (2)
1997 (7)
1998 (22)
1999 (32)
2000 (14)
2001 (20)
AM SXT C TE CE CRO NOR CIP E
100 100 0 100 100 50 0 0 0
100 100 0 100 100 100 50 0 0
29 100 0 57 100 57 14 0 0
45 91 5 64 91 37 37 36 0
50 91 3 16 97 44 19 22 0
57 93 0 36 93 21 43 43 0
65 70 0 65 100 25 45 35 0
* Values in parentheses are the number of isolates. AM ⳱ ampicillin; SXT ⳱ trimethoprim/sulfamethoxazole; C ⳱ chloramphenicol; TE ⳱ tetracycline; CF ⳱ cephalothin; CRO ⳱ ceftriazone; NOR ⳱ norfloxacin; CIP ⳱ ciprofloxacin; E ⳱ erythromycin.
reported in Thailand,7 where resistance to ciprofloxacin is now a major concern. In 1987 and 1990, Campylobacter isolated from U.S. troops in Thailand were susceptible to fluoroquinolones,7 but the incidence of Campylobacter resistance to fluoroquinolones has risen from 40% in 1993 to 84% in 1995.7 In addition, a report from Quebec, Canada indicates that resistance to ciprofloxacin has increased three-fold in the period from 1985 through 1997.23 Ciprofloxacin resistance in C. jejuni in Indonesia increase from 0% in 1997 to 43% in 2000 (P > 0.05). In the current study, no strains of Campylobacter were found resistant to erythromycin. This finding is in agreement with the report from Quebec, Canada,23 but contradicts a previous report from Thailand (1985–1997), which indicated that resistance to erythromycin among Campylobacter strains.24 Salmonella typhi and S. paratyphi A accounted for 6.8% of all pathogens isolated. Although S. typhi and S. paratyphi A are not primary causes of diarrheal illness, they are sometimes implicated in acute diarrheal disease cases. In our study, S. typhi and S. paratyphi A were susceptible to all antibiotics tested, including the fluoroquinolons. Salmonella typhi strains resistant to trimetroprim-sulfamethoxazole, chloramphenicol, streptomycin, and tetracycline have previously been reported in Indonesia.25 Multiple antibiotic resistant enteric pathogens have been reported in many developing countries, especially Pakistan, India, Bangladesh, and The Philippines.26 The cause of the increase in R factor-carrying bacteria is due to the selective pressure caused by antibiotics and other chemotherapeutic agents. These drugs are currently being used not only in humans, but also in animals, cultured fish, fruits, vegetables, rice plants, and honey bees. It has been shown that the use of antibiotics in animal and fish culturing greatly increase the pool of R factor-carrying bacteria in the environment. It seems likely that the use of antibiotics for other non-medical purposes also helps the increase of the reservoir of R factors.12 The use of antimicrobial agents in the treatment of diarrhea has greatly improved the quality of life among residents in and travelers to developing countries. However, the problems associated with microbial resistance in diarrheal patients will continue to pose a challenge to public health workers.7 This challenge can be minimized if governments and associated public health services improve water quality and sanitation. This will diminish the transmission of these bacterial pathogens. Misuse of antibiotics has resulted in increased resistance to most of the commonly used drugs for treatment. A call to regulate the use of antimicrobials may
be necessary. Governments should also encourage the development of new vaccines to help reduce the incidence of diarrheal disease. Data generated from this study identified changes in the spectrum of antimicrobials in diarrheal-related cases in Indonesia. These findings confirm the need to institute long-term surveillance programs, which are essential in identifying changes in the spectrum of antimicrobial patterns of bacterial pathogens in Indonesia. The institution of such programs would provide appropriate control measures for antimicrobial-resistant pathogens. In conclusion, the current study highlights the necessity for continuous monitoring of antibiotic resistance in diarrheal-related bacteria pathogens. Received July 23, 2002. Accepted for publication February 13, 2003. Acknowledgments: We thank Drs. Muzahar, Hanifah Ma, Ani Taufik, Eka Putra, Sukarma, Luh Sriwati, and Hilda Handayani, and Bahar Kaso for coordinating sample collection on site. We are very grateful to all the Enteric Diseases Program staff for their contributions towards the study. Financial support: This study was supported by work unit number 63002A.810.I.2411. Disclaimer: The opinions or assertions expressed herein are the private views of the authors and are not to be construed as representing those of the U.S. Navy, the Department of Defense, or the Indonesian Ministry of Health. Authors’ addresses: Periska Tjaniadi, Decy Subekti, Nunung Machpud, Narain Punjabi, James R. Campbell, William K. Alexander, H. James Beecham III, Andrew L. Corwin, and Buhari A. Oyofo, United States Naval Medical Research Unit No. 2, Unit 8132, Box 3, FPO New York, AP 96520-8132, Jakarta, Indonesia, Telephone: 6221-421-4457/4458, Fax: 62-21-424-4457; E-mail: Oyofoba@namru2. med.navy.mil. Murad Lesmana, United States Naval Medical Research Unit No. 2, Unit 8132, Box 3, FPO New York, AP 96520-8132, Jakarta, Indonesia and Medical Faculty Trisakti University, Jakarta, Indonesia. Shinta Komalarini, Sumber Waras Hospital, Jakarta, Indonesia. Wasis Santoso, Friendship Hospital, Jakarta, Indonesia. Cyrus H. Simanjuntak, National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia.
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