Med. J. Malaysia Vol. 45 No. 3 Sept.

1990

Cholera in Sarawak: A historical

~erspective(1873-1989)
H Yadav, MPH, MBA
Medical Superintendent

Chai Meng Chee, MBBS

Epidemiologist

Sarawak General Hospital

Kuching, Sarawak

Pejabat Pengarah Perubatan & Kesihatan

Negeri Sarawak, Kuching, Sarawak

Summary
Cholera has been in existence in Sarawak for many years and since 1873 many major epidemics
have occurred. The epidemics usually occur during the dry months of May, June and July and
the population affected are those in coastal areas. As in other outbreaks the areas affected
were those which had poor environmental sanitation, poor water supply, poor refuse disposal
and indiscriminate disposal of faeces. Malays are more affected as in Peninsular Malaysia
outbreaks. The classical biotype was common prior to 1961. In later years the El Tor (biotype)
has been responsible for most outbreaks.

Key words: Cholera epidemic, outbreaks in Sarawak.

Introduction
Cholera is an acute illness which results from colonisation of the small bowel by vibrio cholerae.
The disease is characterised by its epidemic occurrence and the production in the more severe
cases of massive diarrhoea with rapid depletion of extracellular fluid and electrolytes. 1 Cholera
is a disease of ignorance, poverty, inadequate water supply, improper sewage disposal poor
personal hygiene and unsatisfactory environmental sanitation. It is well known that the important
vehicle for the rapid spread of cholera is contaminated water. Insanitary personal and food habits
are largely responsible for the persistence and intensification of epidemics. Human faeces is the
main source of infection and it is well known that cholera outbreaks are associated with situations
in which the water supply is exposed to high risk of contamination with human faeces due to
insanitary defecation habits of the people. 2
Cholera has been in existence in India since time immemorial and a description of the disease
syndrome has been described in ancient Indian literature. 3 The Ganges delta has been often
termed as the 'home of cholera'. The world has experienced seven pandemics of cholera and
Malaysia has had its share of the epidemics. 4 - 7
The history of cholera in Malaysia, like other countries in the region, dates back to antiquity
but the earliest known records of the disease appeared in 1823-30 records of the Durian Daun
Hospital in Malacca reported by Sandosham 8 and in the writings of Mrs. Innes (1885) who lived
in a remote kampong in Langat, Selangor.
like Peninsular Malaysia, cholera has been in existence in Sarawak for many years.A The concept
of illness and injury among the Sea Dayaks is closely linked with religion and magic and cholera

194

to the Sea Dayak is the coming of a great spirit from the sea to kill and eat. 9 The Sarawak
Gazette in 1873 mentions of an epidemic of cholera in which many people died of cholera. Also
on 14th October 1973, on board the vessel S.S. 'Hydaspes' between Aden and Suez the only son
and daughter of H.H. the Raja of Sarawak died. Although the cause of the deaths were not
confirmed, cholera was not ruled out. The sea vessels plying in this region in the 19th and early
20th century helped to propagate the epidemic. Up to 1946 all cholera outbreaks were entirely
due to the Qassical Biotype. According to Felsenfeld 10 the spread of biotype El Tor into
SarawaJ.c seems to have come directly from the endemic centre in Macassar and from the
Philippines; the disease moving southward into the islands and was introduced in North Borneo
by a visitor from Jolo island.

Raja Brooke Era (1841-1941)

The Raja Srooke era lasted in Sarawak for 100 years. Cholera was endemic in Sarawak during
this period although very little is documented. In 1873 an epidemic of cholera occurred and it is
impossible to say how many died. Capt. Giles Helyer, Commander of the gunboat "Heartsease"
died of cholera and during this period two children of H.H. Raja Brooke died on board ship
mysteriously, possibly due to cholera. There is also no record of any cholera outbreak from
1883-1886. 11 - 13
However, in 1888 an epidemic of cholera occurred in Simanggang District. It was reported a
great number of Malays were ill from cholera or choleraic symptoms. The total number of deaths
from cholera in Simanggang amongst the Malays, Dayaks and Chinese was well over 80 and
majority of those who died were Malays, who numbered 70. In the lower part of the Undup
river there were 13 deaths among the Dayaks from cholera. There were only two deaths among
the Chinese from the bazaar area (town) and the disease occurred during the end of July.14
From 1888 to 1901 there was no recorded epidemics of cholera but in 1902 another major
epidemic occurred. This may have been recorded as the worst epidemic in Sarawak with well
over 1500 deaths and-the actual number of cases being unknown. It is reported that there
was a severe drought in Sarawak in the month of May, June and July particularly so in the
southern half of the territory. Wells were nearly dry.
At this time an expedition had been organised to punish a group of Dayaks living in the
interior of Simanggang District who were attacking and killing friendly neighbours. A force
of some 12,000 loyal Dayaks including some Malays were assembled, and the expedition
moved up the Lupar river (Batang Lupar) to Simanggang in about 800 boats. On leaving
Simanggang, all appeared well, but when the expedition proceeded some distance up the
river, cholera broke out and spread rapidly. There were 1,000 deaths in the force which
eventually had to retire without accomplishing its mission. The surviving sick and healthy
members dispersed to their respective longhouses and villages. The outbreak started on
about 10th June and lasted until 29th June. The report stated that the Batang Lupar was
polluted with corpses and shields of members of the expedition. Cases of cholera thus appeared
in several other areas and these were attributed to the dispersal of Dayaks after the break-up
of the expeditionary force. Divisions I, n, HI and IV had cases of cholera. 6 The disease also
occurred in Kuching town in a sporadic form during the months of June and July. Overall
this epidemic caused about 1,500 deaths but the number of cases was unknown.
The next major outbreak was in 1910 and 1911. In 1910 there were 85 cases and 67 deaths
and in 1911 there were 109 cases and 77 deaths (Table 1). There were two outbreaks in 1910,

195

Table 1
Cholera Outbreak in Kuching, Sarawak - 1911
Name of Villages/Place

No. of Cases

No. of Deaths

6
4
3
7
14
9
10
4
18
4
2
1
2
3
1
5
1
6
8
1

3
4
2
5
7
5
7
4
11
4
2
1
2

Total for 1911

109

77

Totalfor 1910

85

67

Kg. Pulo
Kg. Buah
Kg. Soerabaya
Kg. Gersik
Kg. Boyan Lama
Kg. Sg. Bedil
Kg. lintang
. Kg. Tanjong
Sarawak Rangers
Padungan
Police Barracks
Samarahan
Kuching Jail
Penrissen Road
S.S. Raja of Sarawak
Kg. Datu Bandar
Kg. Datu Hakim
Kg. Bintangor
Kg. No. 1,2,3,5
Chinese boat for lingga

Death Rate 1910

Death Rate 1911

1
4
1
4
8
1

78.8%
70.6%

the "first occurring in February. Previous to this there had been several weeks of dry weather,
a condition which almost invariably precedes an epidemic. In Kuching, the inhabitants of the
areas across the river of Kuching Bazaar did not have safe water supply and they suffered most. .
This outbreak continued intermittently until the end of April when rains again fell and the disease
for the time being abated. Again from mid May to August there was drought and cholera broke
out again in mid July. Again the natives across the river suffered most. One bf the most striking
feature was. there was not a single case from the bazaar (Kuching) due to safe water supply,
although there was over croWding. In the Kuching outbreak three Chinese, 20 Dayaks, 81 Malays,
two Filipinos and three Tamils were affected. The only outbreak outside Kuching was in Sambir
on the Samarahan river. During a visit to Sambir the Divisional Medical Officer made bonfires
of the soiled clothes and bedding of those who died and the disease abated. 1 5
During the same period the Dutch Governrnent in Java started using cholera vaccination and
claimed the results were good. ID the province of Samarang 8,340 natives were vaccinated.and
only three contracted the disease and one died. However, of the 85,141 natives in the same
district who were not vaccinated 552 contracted the disease and 467 died. 15

196

Although there were cases of cholera in Peninsular Malaysia from 1911 to 1941, 3 there were
no major epidemics reported in Sarawak. A Medical Department report in 1922 suggested also
there was no outbreak 16 from 1911 to 1922 and the Medical Department Report in 1957
reported 'it was considerably more than 20 years since cholera or plague had occurred', thus
suggesting that there was no major outbreak of cholera at least from 1911 to 1941. 1 7

Sarawak as a Crown Colony (1941 to 1963)

Sarawak became a Crown Colony in 1941 after the Rajah ceded Sarawak to the British. From
1941 to 1960 no case of cholera was reported in the Medical Department Annual Reports of
1947 to 1960.
In 1961 Sarawak again witnessed a major outbreak of cholera and this epidemic was very well

documented. 6 This outbreak started on Wednesday 12th July, 1961, when a Health Inspector
from the Kuching Rural District Council reported several deaths in Kampong Sourabaya. This
kampong is one of a number of kampongs lying across the river, opposite Kuching town. Cholera
was confirmed and this epidemic lasted 100 days (Table 2) in which four Divisions were involved
leaving the fifth Division free of cholera. In all there were 301 cases and 70 deaths. Of the 301
cases 113 were found to be bacteriologically positive for cholera. During this period there was
a concurrent outbreak of bacillary and amoebic dysentry. The following were also isolated
V. Cholera biotype El Tor 113, E Histolytica 46, Sh. Flexener 82, Sh. Sonnnei 17.
Table 2
Cholera Outbreak in Sarawak - 1961

Table 2

Cholera outbreak in Sarawak - 1961

''''

Death

220

200

ne
320

lOO

!<,'
140

120

100

&J

~.

qo

62
(Bact.

m)
J2e

40

150

'0
2 C

, 0

July 16
4th day

19"

day

DIV. V-No

'V'\.~.

le
July 12

Same

JulyZ2
11th day

le
No~ame

DIV.lII le
July 29

Aug. 12

lSthday

3200 day

Disease
spre;K\to

",.00

Tot.}

~"

"Ilebd!m&
reladan'

197

301 Cases
70 Deaths

Sept. JO

O::t.19

Anti-cholera vaccinations were given to 444,698 persons which constituted 60% of the entire
population of the country or 80-85% of the population living in the areas considered to be
at risk. The population affected was confined to the coastal areas of Sarawak and hved generally
in villages sited on the banks of the rivers running inland from the sea. It was quite noticeable
that villages above the tidal reaches of rivers remained free from infection.
A smaller outbreak also occurred in November/December 1962 with 16 cases and three deaths

Sarawak in Malaysia (1963 onwards)

Sarawak became one of the States of Malaysia in 1963 and from 1963 to 1988 several outbreaks
had occurred (Fig. 1). The most prominent outbreaks were in 1964, 1972,1976 and 1977 with
198 cases, 85 cases, 177 cases and 223 cases respectively (Table 3). However the most notable
outbreak was in 1977 with 223 cases and it deserves mention as most of the Divisions were
involved.
The first case of cholera in the 1977 outbreak was reported on 21.4.1977 in Bintulu District
in the Fourth Division. This was followed by two cases the next day. By end of May the epidemic
spread to Mukah District in the Third Division. The outbreak occurred after the rainy season
and continued till the end of the dry season. The peak was in August and by October no further
cases were reported. A total of 144 kampongs and longhouses in nearly all the Divisions were
involved. However the maximum number of cases were reported from Sibu (34), Bintulu (26) and
Binatang (15). The ethnic groups most affected (Table 4) were Ibans (61.6%), Melanaus (27.8%)

I -Fig. I

Distribution of Cholera Cases in Sarawak (1960 - (988)

<
SCAL..E

I: 2,000,000

l-="';30~!~=~~';;i,i::-o=-:il~O

K[LOME;TR:

INTERNATIONAL BOUNDARY
STATE BOUNDARY
DIVISIONAL BOUNDARY
MAIN RIVER

o
o

TRUNK ROAD
Mi\IN TOWN
TOWN
CHOLERA CASES

BAHAGIAN KAPIT

t
198

Table 3
Epidemics of Cholera in Sarawak (1873-1988)
Cases

Deaths

1910 (Feb-Apr/
Jul-Aug)
1911
1961 (Jul-Oct)

85

70
Died in Simanggang
mostly Malays
> 1500
deaths in Batang
Lupar & Kuching
67

1962 (Novj:Oec)
1963 (Jan & Jul)
1964 (May)
1965
1966
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984/85
1986
1987
1988 (Jun/Nov)

16
98 (64)
198 (120)
15
5
20
25
85
30
30
70
177
223
1
3
2
27
108
22
Nil
10
15
96

Period

1873
1888 (Sept.)

1902 (June)

109
301

Incidence
per
100,000

77
70
4 divisions involved
Div. 5 free of cholera
(only 5 divisions)
3
7
33

23/1000

7.95
14.53
1.76
0.57
2.06
2.50
8.30
2.85
2.78
6.32
15.60
20.64
0.08
0.25
0.15
2.01
7.85
1.56
Nil
0.66
0.97
5.73

NU

Death Rate Biotype/

per 1,000
Strain

18/1000
7/1000
16/1000

El Tor (Inaba)
El Tor (Ogawa)

Nil
El Tor (Ogawa)
El Tor (Ogawa)
El Tor (Ogawa)

and Malays (7.6%). There were only four cases among the Chinese (1.7%). The M:F ratio was
1.3:1 and there was no predilection for any age group. All ages were affected including those

199

Table 4
Endemic Distribution of Cholera Cases in Sarawak - 1971
Ethnic Group

No. of Cases

138

61.6

Melanau

61

27.67

Malay

17

7.58

Chinese

1.78

Bidayuh

0.45

Others

0.89

Than

Total

223

100

beow one year of age (13 cases). During this period 139 carriers were detected through case
contact tracing. In this outbreak there was only 0.6 carrier for every case which is very low.
The serotype in the epidemic was Ogawa. Apart from 1976 when the major" serotype was
Inaba all other outbreaks were caused by the serotype Ogawa.

Discussion
Cholera has been in Sarawak for a long time and inspite of the progress made in socioeconomic
development and health sector development, the disease is still endemic (Figure 1). Cholera is a
preventable disease and all efforts should be made to prevent further outbreaks. The provision
of safe water supply, provision of toilets, health education, improved sewage disposal and
improved personal hygiene are some of the major activities to be emphasised.
Based on the fact that outbreaks occur in the same areas over the years it is reasonable to surmise
that the organism is present in the environment in these areas during the inter-epidemic intervals.
Why and how the organism initiates an epidemic is still unclear.

References
1.

Harrisons Principles of Internal Medicine.

McGraw Hill Inc., Tokyo, Chapter 155, page
855.

2.

Singh B. Review of Cholera in Malaysia

(1900-1970). Med J Malaysia, 1972; 26:
3: 149-158.

3.

Pollitzer R. History of Cholera. WHO Monograph Series, 1959; 43:11.

4.

Chen PCY. Cholera in Kedah River Area.

Med J Malaysia, 1970; 24: 253-254.

200

5.

Report on the Outbreak of Cholera in

Malacca in 1963, 1964. Committee of
Enquiry approved by the Cabinet. Govt
Printers Dept Kuala Lumpur.

6.

Report on the Cholera Outbreak in Sarawak

1961, 1963, Govt Printers Office, Kuching.

7.

Yadav H. The 1978 Cholera Outbreak in

Krian District. Med J Malaysia 1981; 36:
3: 129-135.

8.

Clifford H. Malaysian Monochromes, John

Murray 1933, London.

9. Roth HL. The Natives of Sarawak and British

North Borneo, 1968, Vo!. 1 & 2. University
of Malay~ Press, Kuala Lumpur.

14. The Sarawak Gazette, 1st March, Government

Printers, 1888 .

10. Felsenfeld O. Bull Wld Hlth Org 1963; 28:

289-296.

15. Scott, WHo Medical Report on the Sarawak

Government Hospitals and~Dispensary for the
Year 1911. Gov't Printing Press, 1912.

11. The Sarawak Gazette, 1st November. Government Printers, 1883; 95.

16. Medical Report on the Sarawak Government

Hospitals and Dispe1)-sary for the Year 1922.
Gov't Printing Press, 1923.

12. The Sarawak Gazette, 1st November, Government Printers, 1886; 92.

17. Annual Report of the Medical & Health Dept.

1957. Gov't Printing Press, 1958.

13. The Sarawak Gazette, 1st March, Government

Printers, 1887.

201