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·E I GRIN
EPIDEMIOLOGY AND CONTROL
OF ENDEMIC SYPHILIS
Report
on a
Mass-Treatment Campaign
in Bosnia

·The World Health Organization (WHO) is a specialbred opacy of the United Nations and represents the culmlaation of elforts to establish a doglo biter povernmental bealth agency As much it laberite the functions of ptecedent organbrations toch utbe Oinet International d'Hypline Publique tho Health Orgotzation of the Land of Nations, add the Health Diridon of UNRRA WHO had his orglo in the propoul made at the Unted Nations Conferenco beld lo San Francisco la 1945 that a specialized pency bo created to deal with all matters relatag to bealth In 1946 representathos of 61 posernmeits met at the International Halth Conference New York drafted and dgned tho WHO Conxitation and aubtbbed in lateria Countdon to xro until tho Cootution could bo ratified by 26 Member Sutes of the United Nations. The Consitation aume into force on 7 April 1949 the Art World Health Assembly met to Genera lo June 1948 eod on 1 September 1948 tbo permanent Organba thon mi crtablished The work of the Oryantados barried out by abres organs the World Health Anxembly the supreme autbortty to welch all Member States and delegata tbe Executive Board the executivo organ of the Halth Assembly consisting of 18 persons dealgnated by us many Member States and Secretariat ander tbo Director-General Tho copo or WHO Interests Rod activities succeds that of any previou International health organization and lectudos programmes relating to a wide variety of puble-bealth questions malaria tuberculosis, vencreul diseases, ober communable okcases maternal and child health mental health social and occupational health autrition nursing environmental antalon, pablic-health administration professional education and tralalag rod health education of tho public. Io addition WHO vadertakes or partidpales la certula techakaal work of International significance such as the compllation of an international pharma copocia the ruling-up of bxologlal standards and of tandards for Insecticides and insecticido-spraying cqwprent, the control of addition producing drup tho achaape of steatise information the drawing-up of International mattery rogulatlong the revision of the international Lix of discotes lod endos death tho collection and dissemination of epidemiologal Information, uod statical Audios on morbidity and mortality

·ORLD HEILTE ORGANTATION
MONOGUIR MIS
EPIEMIOLOGY AND CONTROL
OF ENDEMIC SYPHILIS
Report w a Threatened Capella Benda

·Tbo World Health Organbation (WHO) in a specialized ngrocy of the United Nation and represents the culmination of efforu to cubish ulaglo inter Povernmental health aptacy As much it foberius the functions of Antcadent organizations och u tho Ottico lotermatlonal d'Hypline Publique the Halth Otpantation of the League of Nations and the Health Division of UNRRA WHO had Its origio In the proposal made at the United Nallons Conferenco held in San Fracisco In 1945 that a spedaltod agency be created to deal with all matters relating to bealth la 1946 representatives of 61 povernment met at the International Health Conference New York drafted and signed the WHO Comutation and cutablished on Interim Commission to serve until tho Con sthation could be ruled by 26 Member Sutes of tbe United Nations. The Consultullon came into forco on 7 April 1943 ibe Art World Houlth Assembly met In Gener la June 1941 and on 1 September 1941 the permanent Organiza thao wus culthed The work of the Organtation barried out by three orging the World Health Assembly the mupremo authorfty to which at Member Sutes send delegates the Executive Board the executho organ of the Halb Allembly comialog of 18 persons designated by many Member States and a Secretartat under the Director-General The scope of WHO • fnterests and activities cueceds that of any previous international bealth organization and includes programmas relating to a wide warlety of public health quouillons malana, tuberculosh, repereal decat other communlablo diseases maternal and child health meatal health social and occupational health nutrition nursing cnvironmental unitation, public-bculth administration professional education and training, and bealth education of the public in addition WHO undertata or partkfrates in CCTUALn techotaal son of International Ngnificance such us ibo compilation of an fatetatronal pharmacopocte the settint-ap of btologal sundards and of tandards for incaicos and lasectaide-spraying equipment the control of addition-prodcing drup, the exchange of scienti6c Infomation tbe drawing-up of international unilary regulations, the revision of the international list of doa und cause of death the collection od dissemination of epldemiological Information and Ansbal noda on morbiduy and mortality

·OLD HEALTH OLGANTLATION
WONOAA OD
Ho 11
EPIDEMIOLOGY AND CONTROL
OF ENDELTIC SYPALIS
Rrgut Mitte-Tree Coata baba

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·EPIDEMIOLOGY AND CONTROL
OF ENDEMIC SYPHILIS
Report on a Miss Treatment Capalga to Bosnia
EI GRIN, MD
Direct Contre pour for DLA
WORLD HEALTH ORGANIZATION
PALA DO MATON
QERTYA

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·CONTENTS
h
11
20
22
32
Portword
1 Introductory restaurts on Bomba Hortpovina
2 Orips mod ettet of endant syphilih
3. The concept of codende syphillis
4 Epiden bological comiderttom
5 Natural count of codul typhilis
& Orpentration the idd campaign ainst eadembo syphilis
7 Treatment of eodemic wyptills with PAM and badukas employed
Redactat the recerror of tafection
Samantry
References
Aooct. Studies on treposcuna from cases of eodemlo oppholda
-TB. TWTT & Dante R Hollander
40
72
79

·Originally published under the title Epidemic ophil's In Boer's and Sofia co
treponcona fide chos of codemic philus in the rol of the World Hal
Orolou, 1952,7 1 74 75-81
NOTE
Authors alone are responsible for news
expressed in the Monograph Sertes of the
World Health Organization
The meation of tofactores prodacts do not bmpty that they ar endorsed or
Iccommended by the World Halth Orpentration la preference to other or mallar
mbart wilch tro pot creationed.
PANT IN SWEDELAND

·CONTED
7
65
&
31. stol tborth the (1,200,000 moto of PAX pro toto
te trate of bietlona (Vol
* Uncontrol ubes not worried (VOO Onthorta
J Sobogad dal laptes bu futty obectos (LINO
Dobroren
and trial relaç ka taikyth a fad Socce di
op (MNO Teoddt)
» drone wertica od raketoa la trobfecund mit mod gado
lopoulohet al aborthe tractor UNO per
4. Rex Alador potentiaach badood opt (Trnor)
41 Nuprchlorked and adapta) kodiep word op 121 ct of
coodey wo typeda od 20 woodu er tattoo wtu 6x 600,000
PAH
chfaction of tucah by rotard of the totobar (INO Male
O Secupothytty-tate od ber of cow of modery mph (NOR)
72
77
74

·FIGURES 15 17 10 19 23 33 25 26 26 26 27 27 17 27 1 Proytken of eademde typuha to Bosna od Harropovios, 1951 2 locklence of enteral typhhi la Darth-eastern Bogde, 1906-11 (bud ou dibaal symptores only) 3 Incidence of andere ophilia in northeastern Bosne, 1927-33 4 Incidence of todenok syphill In Dorth-eastern Basel, 1943 5. Femily distribution of codecałe typollos la call lepo sopotni) 6 Rato of mrection with endeuk syphilis by up groups to a fresh focoa (MNO Mutkovac) 7 Proportion of secondary syphitu to total codemi syphilis by trotroops to fresh focus (MNO Mackonec) & Common or tho ibrik one of the most froquent methods of spread ol anden rypbilh 9 Chancro of the breast from Marking Laracted child 10. Primary chance of the peale 11 Secondary split papules at the corner of the month of young boy 12 Mocow patches on the lower lp of young boy 13. Mucous patches on the tongue of young girl 14 Secondary lalong-coodylomata bao at the main 15 Secondary lentong-condylooma laua of tho vulva 16. Secondary lesions-coodylomata of the anal macon 17 Lato soccodary loulons --rupiel nyphilido of the map 14 Exterzelve gallow destruction of the roos and pharyta 19 Orooperioruit of the able with hydrarthrosis 20. Results of rolopal cordmaloos (WARD, Kahn, and Maialde) by 450-poup in 185.aua of umbredted laxant syphills 21 Staudtamoud Appetizoo of Recondary sad tertiary optio Camily with an active foct (MNO Detale) 22 Secondary and tertiary opalub lolamily with a fresh focus (MNO Babolata) 23, Terbury typhilis to a family with fresh focus (AINO Sappa) 24. Distribution of secondary od lortiary mphells (Koson) 25. Distribotion of secondary add tertiary syphilis dijo) 26 Raruits of PAM thenpy with 4,200,000 onlu (MNO Prport 17 Resola o PAM thenpy with 4200.000 mit (AINO Srebrenit) 28. Raruts of PAM thanroy with duiertot schedules Sphy, MNO Zrindo) 29 Rasults of PAM berpy with slaglo injection of 1,600,000 unit (MNO Socesta) 0 Resulta o PAM taupy otth place infection of 1,000,000 und (NNO Sucosa) 31 Resulb & boots After PAM terting with angle injection of 3,000,000 balta (MNO Swato) 12 Rondlo 36 months after PAM therapy with 4,200,000 mlts la 7 Inloctions (MNO Srebro) 33. Distribution of scootery typ bild by studentro dos to delet or Lopen 4. Esed at abarthro traatment in family with a farction (MANO Karta) 28 36 57 38 J9 SI $

·DATE
3
B. Educt of borty trasto con i OPAKO sro Woody
th pretroot of tratta cara (Vaata)
X Vanccadutoka wa family contact you would (WONO Onubente) 65
37 Estadopou mod dicat rapes & Serate with Bow lofaction (UND
Dobrod
1. Surorino od thotel reconds Antly with the foam at
sypboh (HINO Toode)
A
happort section and robledo b two inced tobo colombo
boglan oct of aborth treaca O Sapa)
@ Loretta falloupetunto donde tem focos descope (Tracy) 72
41 Nopeth dhulmd verologio fatiha scoorte tota 121 cm a
condary eadem typulls od X north a trettaro ch 6x600,000
of YAH
73
alacion al cotty by sets of about momber HNO Hada
74
Boropoulo-saw and water one of condut typleto HNO SO 7

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·FOREWORD Secrons be the one and werd op de depend on korte orto Arte Abstacy uk cortes de Coex than that a button be the bottokeat the bretons oorhed out more the stocked popatra #isholu, od partnerty to their art. The desce, htbirs, and Con of in bo pokal, bo cok kontot be condottwendettagom domu to be made mood with common obtu dort, to resoobip berre controeren, wu beton pre od box sont be detondo that perka bocor brand method by both the tort hogy a to date, not to better understanding of the Dior, A, D of mand, dette control of the De Torront sa mot tits the tank bey of myphie de bombe la ha brond me. The Beasta totala bepantem cum dy moreret mogeld n hoor da bu bir baxim to be adok to the serioa lor for cream reach of the bride a Berpe b the 17 Ad id notion by the Otome Hosy pocket of bod popoteaed by people of Twith or were in behind mera Eaug, bukatu tor de bus nautned a pret at A Doucla be the methow tovo when the social and cook on, ocated with wery berlin And of Sintong in prenlw for cartes Metzted a rondet Arvoorable w repreparata o kod the two of Tromp pe by met and botorect contactatio go, Tha spalda ebolocal attens ho parlared the start od k sather to do which had o Crochuthats Entrad when the best maapind on trady acquired op afroat cheltzez The se estar the Lederson 16th-century Morwy od to other partid tego co dopo lo dildes kod demons columnes al Ewropolo to it and Ada taques 7b tural cours of pala nagked ba cildhood borac i poglologial, data, laborary and out oportet, kus wor boca suporty deserted to add W pracy reprosto portiunt coelothes both botod low de on the fact. The or troncal factors mad taetr UADCO as the perpedom d the basection Monitors de tou coon of tan diw one docet, pre Control dort er det, bacta sboot this to typu optikos inspired and apps theories and one couldertow bar stoond aastate as chloork prox Onomat The postep, therefore, Dok Dohorts troca to post of the order og od the accessori pon-renere opta problem in Til tro, and babe warto pay medical bronde, but boottabo be of wooden bile rulou o te word of other tripoorno, cabe porn and partheirty buch hon special fustanta ar to thon adezik ophide od do ta to the madrats and furthermont, i tady controlled the den plat for bou pocet mere pot boulot la perte de conduios. A cont property OPER, ** pretend that the real tip wendy wbt.hed to the people stood contato te prometa o local bald po On

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·FOREWORD Swaroto prew control of toy de depende a boost of tard Wory Hot boy to good borone ter bith doulettes Bott be ortodon to tond population Anok, od perteksty o to portrets. The concreta, babetta, od corto al pical, portal, old, and cook orrow. We be cond the dead on toro bo nderstood wie ook cette teoretiko bat hos dentroament, bet po udbou, and be so the dog betona brodotbod by the on Watcy of the countdockatod, and to be done of the Petr, ok, DOD O out, od rental coord of the time Tbo pro rat koopt o party the water blatory of type de Docto bronder de Toulomka man to do y Domy red budod, wild has been how to be madera ha the room for by com reft of the moon of Doropo de 17th und the cotada by den Ouomt. Wim pochots of bod popold by people of The area on heldban Lope, which to the toond wary phat wall rootort tot out to best of thom een bore the social cod cook contidoos, od very low todards of hype end of long bol, her for math triped to controanable to repeated power to the tale of Troponton menty do od oca co-oorte Dick Th cho worlaltia pepe tool the pet do odbior to that wild Crop Pogband who the Sibbers van weprodowy crood wypoda doctor la calderes. The won appliar to the Bademy to 160 cotary Moroty rod to odrer Docted reporteractions to be found in dienst con of Curope in the lohd Ith storia To con oltabit tied to dodhood, cbatong pidemiological dkdbhansory tod och ropotabes mot tos no cetat died in one hat the point taty repromo portant contaboon to boosted by body on the react. The artrood om and the top od popetuntoa af data con alto do or decade, pot control or are con lucts about the world type of pain bed world theorie und Poodoosrod ega boro ba the tott, Thu, terfon, ** oo ol mere from topolat of wine of picha motogod the odd control of Norral types problem la rontoon, od bet porto primiti Loos, but thoshtho ba o condenable u du control of the reports, toca abelhor od portal of doonopolul feature to tofaden og da als de moto dal mindent Fartbermoor, the staty he told to de artrool pro tot both poco al poteh Doklat moder wolletto A Inocoon ma beba ponti addetta toodeto dready budete poople oswoord voorbere to to protect of ballad O.

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·CHAIUI INTRODUCTORY RESLARIES ON BOSNIA-HERZEGOVINA Tbo Peoples Repubio of Bonale mod Herzporima occopies a central proprapbocal politice mog the Federal Repabila or Yoposante ft & the third largest with an uros of 31,567 krop of 2.7 / of the Yugoslav territory A coast of me popptical with, Bonda oftpying the portbara od central part and Herzegovina the southert. It la predominantly montatoors, 66% of its territory coosisting of modotatos lod blghlands with a toul wooded vrae of 2,134196 bocturn. Asibo froster of Bomla and Herzegovina tho tempante contientul loomto meet the Malitetnog matt Central and matera Botade borre a typical Central Ewropean coate with cold womy winter and moderately nem rommer Frroureblo entoral conditions for provides cerak and tralt treen particularly phum titti, umple resources In moerbs and ora, ottentre foresti, und da reserva dl water-pourer etre un colleat bexts for the mapidly developing toturiakimdoo of the country Oo woooot of the Crotrable natural condition, the prescot territory of Bonda-Herreporlaa mas mattled u long to the remotest prehittorio thues, the chief representatives of its ancient crimadon being tho Mytlans. They were obogated at the bepaalog of the lot century AD. by the Romans, bo ruled these sezlons for moro the four centurion Ater the sptitriac-op of 1sc Roman Empire bruto the Eastern und Wetan Empires, the area ocupled became the theatro of conflict betrece Eastern and Western dvitation The Box Slant marted to tardo Bosnia at the beginning of the 7th century mod ba the valley of the stres Bosse they formed the cort of a medical Suar Darlay the course of Wstory party at its pracot provido bocam. ttched to Bosnia, and a boundarins contesponded more or loss to the present frontiert. Meanwhilk, the Stato ma tot parkenlarly trough organized, and Borta come moder Turtle role at the begłanlag of the 15th century without much redistance. Thus, it came to occupy a #ratetto position between Ett id West Tertib Tale in Bouis Herec porta made i det uod being impression 0 Local, conxumi, uod cultoral bit, and the folocnon Idami duit aatioa bereme predocant. Tho Motammedestrad population, though it bad brokro od almost all contact with its padocal tradition, il retted the lipopood roma arstos o pedbo sathcoal mart. Macowbig, the rol find experienced caftan od onomo xadion, and the Handard of He remained endly potentive.

·10 EFIDEOLOGY AND CONTROL OF ENDDIC SY HILLS Since 1945, tho Yogoury health administration be developed a moorwio opbobo control program u part of its renal baulth activities La Book, a special clfort bts boen mundo to control codemic plllis u part of the panel program for social and economic development. The World Health Organizatioo (WHO) md the Uoltod Nations International Children's Emergency Paad (UNICEF baro participated in the programm at the request of the Yopouley Gomernment. International Interat la the codemak syphilis In Bounta, however ko not recent date. In 1933–4, the Rockefeller Formation pupported top Deld toda loto tho paturo of tho dicate with a view to definidog the differences that were believed to act between the codecals type of syphill found in Bonda and the spondio veneraal syphils found to other parts of the world. With the locate of com opantao mong mations in mittai of health after the wecond World War and, co the tochndaal de, der the latroduction of repodtory penicillin preparations, I bocado posible to approach this problem olarpo malo od bo moro practial tone A vido custo-finding mod trestment progreso hau been ta operation to Bomla doce 1945 and It bas attracted partiador locational Afteotoo u one of the first stemde promes in the world shed a linboating in eodepois Infectious disease through ma treatmcut. Preliminary diktadors between the Yugoulay bealth actininistratioo and WHO wakich took placo 1A 1947 and woo followed by a deld stody by Dr T Gutha of W710, Add Dr D Borcostein, or UNICEF led to the formuladoo of plan for the current profitne aptenderalcoyphius in Bost u part of the nationwide ophols-control pro trutta. Varios fupplies and equipment furnished by UNICEF and werel WHO expert consultant and advert hare rabacqueally studied the Bocolan progreso to its different phase of development, utpoog there Dr Evan W Thomas, Professor al Clinical Modicine, Now Yort Untreuity and Ds E. Guney Clark, Profesor of Epido molog Colombia University ta 1950 100 1951 Tho planning, broplementation, and follow-up of the poorten har been the responsibility of the Ympostay bealth trail nistration and of the Fled Director Dr E L Grio, Director of Health, Sarajevo, the author of the present paper Asi complemeat to this study Dr TR Turner and Dr D. H. Hollander of the International Trepoocomatost Laboratory Center submitted a contribution-padhed # Ab anna-on two units of Tropema polidon bolated from two Bocolan patients. At the request of the author Dr EG Clark modertook to cofrimcat on and demo various pocty of the mom cumpain Hba ve vere embodiled to a paper presented to the fourth tion of the WHO Expert Committco oo Veneral Infactions and Treparo motoren, whilch met in Loodon from 28 July to 2 Aprost 1952 This paper with bo foncluded in the roport of the Expert Committoo, which will bo publeshod bo to Word Reall Orrepotto Tecal Report Series Bibject to approval by the Epocutivo Boud ·CHLATTER 1 INTRODUCTORY RERLARIS ON BOSNIA-HERZEGOVINA The Peoples Repetto Borda end Haraportos Occapio a contral romptical portion on the Federal Republic of Yoposlavia. It is the third part, with ab und 31,567 kW or 20.76 of the Yoposlav teretary It counts of tho promptial units, Botola occupylog, tho Bortbeta and central part und Herrepovina bo wontbers. It is predominantly mostatoes, 66% of its territory coaching of mortatalos od Lighlands with a tool wooded ua of 21341% bectarea At the froode of Bocola Ind Herze poring the temperato continental climato meets the Meditampean amato Cootrl und rastom Borala bene a typical Centrul Eeropean climate with cold, spory waters and moderately warm en Frrourable natural conditions for growlox ceraub und Indt troca, particolaty ptum trees, ample resourcer la morals od oral, criandre forest, and ride record of war power give an excellent best for the maputty developtog todostrialization of the country On merount of the laroerable standi coodition, the present territory of Bosnia Hertetono mo attied us ho apo the report prehistorie times, the chile repascotative of its cocleat dritation being the Lilyrtarih They wero mabopted as the banding of the lg century AD by the Romans *boral these repops for more than four conturlan Anar the splittios-op of the Roman Empire Into the Eastern and Hestern Empires, the area Occapied because the theatre of contacts between Eotter and Western chillation. The first suurt kerted to itido Bora at the begionlar of the 7th catury and to the malley of the dra Bost they formed the com o apocal Stato. During the course of history party at ts present provinces becue attached to Boots, add its bogodartes corresponded more or lead to the prest frontiers Manthi tho Suto vas bot particularly sroody orgatod, od Bonda ame ander Turbish molt at the beginning of the Sth tory without wine tapet Thum, t cam 10 DoCopy gruteplo position between Ear and Wat Tortish rolo la Bophila Herrerorla made a deg od lexiog improdon on modal, codoodle, od anthral ta, tad the interact of Lank crit alco benton predomiotat The Mohammedastad population, tborata Ld brot off almost all contact with its national tradition, all related the app mod noon koos als pocito national mart Manwhile, the rural Histoista palesond cultural ipd economie spation, usd the Hraded at He reculood testy peleithre. - 11 - ·10 EPIDL NOLOGY AND CONTROL OF ENDDAC MALI Since 1945, the Yopoulry bealth andalatrabahu dorloped a medioawie syphilis control propratomo u part of its reoen) bealth rethitta la Botola, a portal dlfort bay been made to coatrol codetel opuitis u part of the poem programs for social and economic development. The World Health Organization (WHO) and the United Nations International Children's Emergency Pund (UNICEF) havo pardcpated lo to propu.com utbo request of the Yopoday Government International Interest to the odernic typhilis In Bomh, bomover b not of rocent date. In 1933-6, the Rockddk Fondation apported mdoml Deld Audles into the outure of the dress with a low to define the culleroncs that were believed to chat between the codeunde type of syphilis found to Borta and the sporadic venou ryphills found to other parts of the wodd. With the Inau aopanton unong nations in matters of bealth after the second World Wa, and on the toctonical side, wer the Introduction of repository penica popunitions, It becamo possible to approach this problem on a lanpo culo end la mort practical mana A wide cuxc-finding end treatmeat proprezano bot bos la operation la Bowla doce 1947, and it has attracted particular tato pational attentioo u one of the fint systematic pro mumes in the world alred a dantrating un codenasc toroctious dihase throakha mo trecut. Preminary dbacisions between the Yopoulty bealth administration and WHO, welch took place la 1947 and pero followed by a Bald study by Dr I Guth, of WHO od Dr D Bortostatn, or UNICEF led to the fortmulation of plan for the current propunto pin codemic sypill in Bosnia a part of the parlamróa typo-control program Vorlous Rapplies and equipment were tumlibed by UNICEF and several WHO expert consultants Rod andren have a bacqueatly studied tho Borbo progradouro to it different places of developarant, amoot the Dr Erma W Toomas, Pralcmora Cunical Medicine, Now York University tod DT E. Gurney Clark, Professor of Epide mlolots Colombia University in 1990 and 1931 Tbo pluring bonplementation, and follow-up of the programme hitro boon the repoolbility of tho Yaposir balth adm Albatrition and of the Field Director Dr E. L Odn, Director of Health, Sanjore, the author of the present peper As a complement to this study D T B Tuner od Dr D H. Hollander of the International Trepooematode Laboratory Contor peboritted contribution published a konto two strains of Thoromena palubor bolated from two Bomino patiotu At tho roquest of the cathor Dr EG Cart Cancertook to comment on and disco various tmpects of the man ampato Horlows hero embodied in a paper presoted to to fourth porslan of the WHO Empert Committee on Veneral Infortions mod Tropoonmaton, which met to London from 28 July to 2 August 1952 This paper will be Included to the report of the Expert Committee, which will be published in 1bo World Pada Orrentration Team Report Soria rubtect to approret by the Executivo Bound ·NODUCTORY I ON SORULA-HEXAGOVINA 13 torapa are merg festet mbogked, sodit b imponible to draw chnical frontlers. The problem s prenesated by the Moulez population is being solved by encouragtory that cabul, educational, rod social development in order to broy the more speedily to Aage where they will realizar that they beloor to the the Sutan or the Croatian choial prottp. According to the ones of B3 March 1945, the most important sodal Po wro a fobom pestants, 1,966,406 industrial workers, 31 400 mint, 1850 mm, 31,281 and tradame, 12913 [o the praet posted on social mod borom reorpntation of the landsstrial trochure I continuous dappe ts sans plus in the mountal composition of the population, which by locatdog rapidly to towns and lade trial centre Tho Dopalatia of Santone, for improce, lowered by 57 67 between the liberation and 1946 There are no le chia to the Peoples Repable of Bamla and Hera porn but, abs Other Ballar comentrian, there any Dom Out small towns od moment, Santo is the industrial, political, caurul, and comprot autod centre of the Republike in cultural terportance has increased condenably pop the foundation of the Vatrenairy thero la 1849 ·12 EPIDEMIOLOTY AND CONTROL OF ENDOC SYTHIN Turkish ruk lasted until 1878 when the Congress of Berlin gavo Austru Hungary I mandate to enter Bosma. The Austrian occupation of Botola-Herzegoving, with its semicolonial methods of administration, provoked a xrong national movement rating in the strastination ut Sarajevo in 1914 of the heir to the Austran throng tho Archduke Ferdinand. In 1918 after the first World War the newly created State of Serbs, Croats, and Slovenes brought about no essential social or economic changes in Bosnia Herzegovina, and the much-hoped-for cultural and Industrul development made but very slow progress. Bomnia Herzegovina remained, In fact, only a sphere of interest in a common State, while religious and national differences became more and more scute. At the beginning of the second World War when the occupation was followed in this part of Europe us in others by a struggle for national liberation, which started on 27 Joly 1941 tho crisis threatening social, national and political disintegration and economlo stagnation was fur mounted. By paying a hugo toll in homen life (the war calmed 700 000 víc tims in Bosnia-Herzegovina alone) in muffering, and in material losses, the Federal People & Republic of Yugoslavia was created. The People s Republic of Bosnia and Herzegovina is recognized uodes the Yugoslav Consutution u i member of the Federal Repubhc with equal rights. The low cultural standard prevalent in Bosna Herzegovina during its histoneal evolution is best illustrated by the high literacy rate. The Austro-Hungarian occupauon found t population more than 95/ tlltterate, but compulsory primary-school education was introduced only in 1911 Actually not more than about 15 / of school-age children went to primary schools, and Moslem girls did not go to school at all. Omog to these facts, there mu no real progress in the cultural life of the population. After the first World War the population of Bomnia Herzegovina rus still about 87 / fluerite among the Moslem womocn, who had almost no rights and who lived in complete subjection to the men only 1 in 1 000 was htcrate. As late as 1939 56 4 / of the men and 876 / of the womca m Bosnia-Herzegovina were still illiterate. After the liberation, rapid progress took place, and between them and the end of the scholastic year 1949-50, about 600 000 persons had learned to read and write, whilo the number of primary schools had increased from 1,043 to 1,847 Tho population of the area is 2,565,277 (1,237,381 malo and 1,327,896 female), or 16.3/ of the total population of Yugoslavia. The contul population locrease 1 227 In the highest rate among the Yugoslav Repub Ha. The average population density increased in Bosnia Herzegovina from 45 per m' in 1931 to 49.9 in 1948 The population is denser to the north, where cereals grow well, and is less dense in astern und central Bosnia Ethnically the population of Bosnia Herzegovina is almost acustrely Slay being composed of Serbs and Crotti Geographically these two ·17 ORION AND TEXT OF RDDXC THU necha oy UD TIDLOXTUMN Lotte PUAB OR CONCAL SITO Onn the porod between the fore second World War, for cumple, werd de btt lagleg ronth were red pory in theated wms won the friloctivo-ata w ofien orta are wind postbo mort laporunt population centru when the propune could be wort är prised. Lotted to protects to thring Randards and weary condition tomo theat took place in och tot, bet cały with cocotty od they reach ter attentathlon calle o door Bolt The extra of wobo, porch of Sancto brood uplo of an ook where peau torprotnout na wodal v sodoodle godities companied the derdlopment of a phillicoptrol programme. Durthe the option of 1903-11 424 of the population of the darla u toud to bere cila muntfattom of the dihen, od 3251 clinical men dan moet there were 2011 aos of arty turecto Crocooler) After the trx World We stoodthal Soutrof work teta, od goda Bold Ikala mo mabothed. Lo 1936, ·16 EPIDETOLOGY AND CONTROL OF ENDDIC SYPHILIS weto found, 17 746 to the early stages, 6043 to the tertiary dage, eod 33,276 in the latent stage. The infection-nate among the population camined us 11.8% As there was no uniformity to the organization of the programma, in the diagnostic procedures used or in the control of infective casa by follow up or analysis of the data collected, the findings were not sufi dently reliable to form a basis for sauld conclusions on the true nature and attent of the problem at the time or on the effect of the programme Nevertheless, the observations made give valuable information on the geographical extent of the disease and confirm that syphilis was endemac, and sometimes cpidemic, in many parts of Bomnia Finally za 1941 at the beglaning of the German occupation, plans weto drawn up and un attempt was mado to launch a general campaign to olimunato eademic syphills as a rural health problem in the arca. Little progreut was made, however and the undertaking was soon abandoned. The situation was aggravated durlog the mur by the migration of large number of refugeat and by a further deterioration in Uvog condidons and sanitation this gave rise to a number of new endenlo foc in towns and rural areas Fig. 1 shows the areas of Bosnia and Herzegovina wharo eodemic syphilia was prevalent in 1951 The main reasons for the foluro of previous forts to control syphilis la Botala aro considered to be the following 1 Action against the disease is not undertaken simultaneously throughout all the infected areas and, in those areas where control efforts were made, there were frequently long lnterruptions in the work. 2. No syrematio cumination of the entire lafected region 23 attempted, soch work belog restrictod to stall areas only large number of cases were therefore not discovered, and aumerous small und largo fod of Infection remataod. 3 Empbads was placed on the clinical and pathologial, rather thua on the epidemiological, uspects of the disease. 4 Modern antibiotics were not avaluable and only a small number of infoctious cuses completed treatment with the classical chemotherapy methods, which were not suitablo for mas wort in isolated, aod some times mort inaccowblo, nonl areas 5. Low socul uad cconomic sandards, primitive noitetog, zad poor living conditions, remaining almost unchanged, arrated a favounablo epido miological carronment for the recurrence of aisa and for the perpetuation of the disease It would, however be incorrect to give the impression that the previous cfforts to combat syphilis la Bomia pero of no nlue The activities la ·17 ORIX AXD IT OF EXORA STERLO tarta of toe manba ne moram NOKIA - TO o abocat TO On gala the poriod between the test and recood World War, ſot kople were Auct but becas retrite te ciod only la Salud uw where the doors often by OT is gats med bor ( ROTO Raspostest population derarts where the programma twold be thote tasily impervised. Lirotund Improvement in Aries words and potary conditions to titrat took place at the to, but only with matty Hd thy ranca artalo others to the lo sconto piom of Bogota The distrat of voto, worth of Serjero, bo pod amplo of an wert s pot tenproverscot to model and economic conditions Locomposed the donelopment of a syphith control programme. Dreator the typhoid farvey of 1905-11 12% of the population of the dark u toned to re dotal mtaflaudom of the time, 3,251 ctinical A were depored mout that rett 2231 courty infection (oooodasy) typhlins. After the art Wit War Iottom control work I modules, tad man te man bod. la 1936 ·18 EPDECOLOGY AND CONTROL OF ENDEMIC STIHILIS when the average Infection nato pas 18.7 / the great majority of the persons infected had latent syphilis.* This programme was contined until the second World War and, during Investigations carried out lo 1950, nearly half a century Liter the initiation of control work, the Infection-nate was found to be only 3 17 / again with the great majority of the cases in the latent stage. A similar improvemeat has been observed in a few other frontier areas but dumerou endemic fod remained, particularly in north-eastard Botnia, where there wus do appreciable change until the present largescale programme (1948-52) described in this paper Fig. 2, 3 and 4 how the recorded provalence of endemo syphilis in north-eastern Bouna before the first World War between the wars, and after the second World War respectively Fig. 4 is based on the systematic furvey carried out at the beginning of the present mass campaign. It is apparent that no marked changes have taken place in the prevalence of syphils in this area mince 1911 Variations in infection-ratos are to be AQ.1 INCIDENCE OF ENDOC SYPHILIS IN NORTHEASTIRM BOSNIA, 100- Dom WIL Toe SEROLA

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·CHAPTER 3 THE CONCEPT OF ENDEMIC SYPHILIS From observations made over the course of years a, # # , A and from information gathered during the present syphilis-control campaign in Bomia, It is apparent that the essential characteristics of this treponemal discaso are as follow 1 It has, as a rule, a non venereal modo of transmission and is not considered i venereal disease by the infected population it affects both Xin equally at all ages, but is most frequently acquired in childhood. 2 It is prevalent in areas where a low standard of education and poor economto and social conditions, with primitivo unitary and dwelling arrangements, aro general these factors make for repeated a posure to treponemes, and the direct and indirect spread of disease is greatly facilitated. 3 Its particular mode of spread, through common domestic and household utensils and other direct and indirect contacts, often results in the appearance of infectious mocow lesions in the oral region as tho first typoptoms 4 There wo no essentul differences in the naturo of the symptoms of enderlo syphills and those of sporadlo veneral typolis, the symptomatology of both including cardiovascular and neurological lovolvement. It will be seen, therefors, that syphilis in Boria most bo conddered primarily as an epidemiological rather than a clinical problem. Tho Infection becamo eademto becaux of tho canistence over centuria of cpt demiological fatores favouring a cartela mode of spread. The term endemic syphilis" subsequently becamo associated oth non-peneral typhills, usually acquired in childhood, in which repeated crpoforo to muall numbers of treponemas oro u period of timo give rise to the prodominanco of certain features not usually encountered in covironments where veneral trapanission makes a different age group primarly out ceptible. Syphilis cannot dovelop or persist in this endemlo form if tho various cavironmental factors referred to above are absent Similar considerations are probably applicable to other non-venerally acquired treponemal diseases, such us befel , and - "Djovera both non-venerea) treponemal infoctions generally encountered in chilldren 10 Middle Eastern Aden, and African populations In the early Bosntan control-programmes, emphasis was placed on the clinical uspects of the diseas, and certain CITODCOUT conclusions were drawn, in particular that this infection wus & benigo lines. The resulted - 20 - ·TAX RT OF DOC DO 21 in toroident attention being paid to the real nature of the problems and delayed the abiklurrent of mixtio pablo-halth more for the control of the dran. It was not the beglantos of the present sarpalga that it became evident that the major emphasis bad to be placed op the kemi foglal perts if the dimonds to be remotely controlled.

·CHAPTER 3 THE CONCEPT OF ENDEMIC SYPHILIS From observations made over the course of years and from information gathered during the present syphilis control cumpalga in Bosoin, it is appareat that the essential characteristics of thus treponemal disease are u follows 1 It bus, us a rule, 1 pon-venereal mode of transmission and 6 20 conndered a vaereal discase by the infected population it affects both texas equally at all ages, but is most frequently acquired in childhood. 2. It is provalent la arcus wocto a lon standard of education and poor conomic and social conditions, with primitive coltary and dwelling artiogements, are general these factors make for repated exposure to trepoocman, and the direct and direct spread of disease is greatly facilitated. 3 Its particular mode of spread, through common domestic and houschold utensils and other direct and indirect contacts, oftea results In the appearance of Infectious mucons lesions in the oral segion as the first symptoms 4 There are no essential differences to the nature of the symptoms of endemic syphilis and those of sporadic venereal syphilis, the symptomatology of both including cardiovascular and neurological involvement It will be seen, therefore, that syphilis to Bomnia must be considered primarily u an epidemiological rather than a clinical problem. Tho infection becamo endemic because of the edstence over centuries of cpit demiological features favounog a certain modo of spread. The term * endemic syphilis ™ subsequently became associated with 00o-vepercal syphilis, usually acquired in childhood, to which repeated exposure to small aumbers of treponema over a period of the gres rise to the predominance of certain features pot usually cocountered in environments whero venereal transmission makes a different age group priority to ceptible. Syphilis cannot develop or perust in this endamfo form I tho Yano environmental factors referred to above art abstat. Similar considerations are probably applicable to other non-venerally acquired treponemal diseases, ** auch us bejel 4* and nfovera". both con-venereal treponemal Infections generally concountered in children in Middle Eastern, Asian, and African populations Lo the early Bosnian control-programmes, emphads was placed on the clinical aspects of the diseases, and certain erron cous conducions were down, in particular that this infection musi benipa Illness. This resulted - 20 - ·THE CONCEPT OF Eonuc 21 En mot cleat attentka bere peld to tboral patare of the probleme and delayed the establishment of rabatle pabile salth magres for ibo control of the back. It was som motll the beghalay of the preteet ampalan that it became trident that the major topbeste bad to be ploed on the opklandological gathe stoms to be possfadly controlled.

·CHAPTER 3 THE CONCEPT OF ENDEMDC SYPHILIS From observations made over the course of years 11. , 2, 4, 4, A and from Information gathered durmg the present syphilis-control campaign In Bomnia * It u apparent that the essential characteristics of this treponemal diseas are u follows 1 It bas, us a rule, & non-venetaal mode of truosmission and is not considered a venereal disease by the infected population it affects both RXA equally at all age, but is most frequently acquired in chilldhood. 2. It is prevalent in areas where a low standard of education and poor CODOTO and social condition, with primitive sanitary and dwelag arrangements, are general these factors make for repeated exporure to treponemes, and the direct and lodirect spread of disease is greatly facihtated. 3 Its particular mode of spread through common domestic and hourebold utensils and other direct and indirect contacts, oftea resplus in the appearance of infectious mucous lesions in the oral region as tho first symptoms 4 There are no essential differences in the nature of the symptoms of endemic syphilis and those of sporadic vencrcal syphilis, the symptomatology of both locluding cardionscular and neurological involvement. It will be seen, thaefore, that syphilis in Bosnia must be conddared primarily a en epidemiological rather than a dinical problem. The infection became endemic because of the endstenco over centures of epi demiological features favouring a certain mode of spread. The term * endemic sypbillssubsequently became associated with non-venereal syphilia, usually acquired in childhood, in which repeated exposure to small number of treponents over a period of time gires rise to the predominance of certain features not usually encomtared to environments where veneraal transmission make a different age group primarily subceptiblo Syphilis cannot develop of pang to this endemic for I tho various avtropmental factors referred to above are absent Similar considerations are probably applicable to other non-vedercally acquired treponemal diseases, *. * such as bejel, and plovera both non-venereal treponemal infections generally encountered in children in Middle Eastern, Asian, and African populations. We do Lo the early Bosnian control-programmes, emphasis was placed on the clinical aspects of the ase, and certain erroneous conclusions were down, in particular that this infection was beniga llocs. This resulted ·THE ONIT OF DODOC SYD 21 to fortident attention being pold to the real nature of the problem cod delayed the stablishment of raistie publobealth mantra for the control of the discux. Itu so toll the besoning of the present ampelon that it became ordent that the major emplach bad to be placed on the epideradologlal aspects thodbour was to be procedeully controlled ·CHAPTER 4 EPTEMOLOGICAL CONSIDERATIONS In Bomnia, endemio syphilis is mainly found among the rural population, but it is not cvenly distributed over the different areas, despite what appear to be identical living conditions. Sometimes one vage b heavily infected whilo a neighbouring opo may remain free or have only a few cats infections may be found in one group of houses in a village while other groups remain unaffected. There may be comiderable vinuations in infec tlon rates within one region, and even within smaller communities. For instance, lo ono district (Zvornik), which includes 16 administrativo umts, 41 833 persons prero systematically qurmined. The general provalenco pru 13 7 / whillo the prevalence in the administrativo units wined from 57/ to 24 8% If a comparison 1 mado of the infortion-rates in the various villares within one of these units, the variations becomo cven more marked. Thos, un an administrativo unit (Sapna), with a general prevalence of 24.8 /.. the minimum rate was 4.2 / and the marimum, 60,1 %. It is dificult to explain this woeven distribution of endezake syphils rocal and family customs, migratory factors, the topographical Arturo of the country and poor communications, which hinder easy access to certain places, may bo important factors A family "map of the inbabitants to a tmall village i dvea la ig. 5 This tadioates that closo family links, and social contacta, constituto 10 important factor io facilitating the spread of the disease. This examplo is taken from Investigations in a Moslem villago before the second World War although certain social customs no longer exist today for fostanco, the frequont changes of wives, the findings and still important. The villago was founded by three brothers (abom as, M, and S) ull of whom wero infected with syphilis. With tho arrival of newcomers and Intermarriage botweca tho fohabitants of tho village and those of neghbouring settlo ments, tho community apardod. At tho time of the investigation the village mu three generations old and bad 25 dpellings with 116 lohabitants (61 malo and 55 formale) 44% of the married women and 36-3/ of tho married men had been married two or more times Ad the familles la the villast, with the exception of Ave, Hero related to one another A high tafection-tate (56.1 s resulted from the dose contacts which existed between the households. As a rals Bosplan villages are not compact commodities with the houses dastering together or pemi-detached but we dispersed over quite - 22 - ·Tupad ECAL CODELATON LEY OOSTTg 07 DwDoc Man LA QUL MUME POTOTHO * ** 8667 8777 dia 883 QU wo OH berpura, tuber Lodbrdmiry as in small poogn A Rody of the peoniaco of codesk typbits to relation to the hot of the most rettes that iba per mod on compact the comintunity the higher the infection- Tag, stoce there are more opportunities for the trusledop of treponema Toort, y rectothy carried out to a rilepa in highly infected as part of the present control proprio ubon i proprero decrow to the lotectionate us the population fouteen. Va pas mba popote thor of to 20 bud overp totoo #oof / those with from 200 to 400 poopke 162 those with tron 400 to 600 people, 126 od thoto with over 600 people, oohy 9.1% neu RATT OF portCTION WITI DA YA DY ARO HA MTK racun Q LALAYA 13 HAX ·24 DE COLOGY AND CONTROL OF ENDELIC SYPAULDS Fig. 6 show the absoluto distribution of endemic syphills imong age-groups however it will be seen from fig. 7 that there are wide differences in the age-specific mfoction-tates, tho highest rate of secondary syphihs being found in children, MO. 7 PROPORTION OF ECONDARY SYPHI TO TOTAL DIDEMIC SYPIS SY AGHOROUPS IX A FRESH FOCUS (NO MACKOYAQ 41 뼛 1 2.0 ILO 21-10 41-30 Humber of inhabitant LR4 Arap infectionate 14% A similar distribution is found in the case of untreated latent syphilis If quantitativo serological reactions are used as an lodex. This is illostrated in ing. 20, from which it will bo seen that the highest 18c-speafo infection-rate of positive stological reactions is found in the age groups 0-10 and 11 20 Fig. 20 also shows that, ryphllu is allowed to follow Its oatural course, the higher the age group, the le frequent the portivo terological reaction. In urcas where endemic syphilu is actively spreadiol, the percentage of children infected is particularly high. On this basis, condusloos aan bo drawn as to whether the disease is increasing or decreasing in a particular Arta in other words, wherever a high proportion of infected children by found, syphilis bs moro activo and the codemto spreading while in places where that proportion blow the disease is les active and the enderlo waning. Au fresh infections among children become rare mort cases of latent syphills are found in the higher age-groups, and a larger proportion of the lower age groups remain uninfected. The mode of transmission of codemio syphills to Bomia b mostly Don-vencrcal in character The rural population does not geocrally associate the disease with sual contact, and cademic syphilis doa pot

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·24 EPIDDIOLOGY AND CONTROL OF INDIC SYTHIN Fig. 6 shows the absolute distribution of endeak syphills among eft-groups however it will be seen from fig 7 that there to wido difference in the age-specific Infortion-ratas, the highest rate of secondary typhilus beapg found lo children, ne 7 PROPORTION OF SECONDARY SYPHL TO TOTAL ONDEC TYHLH BY AOE-OROUP IN AMEOK FOCU (LINO MACKOVAQ Se mere na 0-10 ID LO 01-50 21-0 App Number of inhabitator 2 Arange Infection-re 14.4 X A similar distribution is found to the case of untreated latent yphills If quantitative scrological reactions are used as an inder. This is illos trated in fig. 20 from which it will be seen the the highest age-specific infection rate of poultivo xrological reactions is found in the age groups 0-10 and 11 20 Fig. 20 also shows that, if ryphilu is allowed to follow Its natural course, the higher the age group, the less frequcat the positiro merological reaction. In areas where endemic syphilis is actively spreading, the percentago of children Infected is particularly high. On this basis, conclusions can be drawn as to whether the disease is increasing or decreasing in particolas area in other words, wherever 1 high proportion of infected children be found, syphilis is more active and the endempio spreading, while in places where that proportion is low the disease is less active and the endemic waning. As fresh infections among children becomo ne mort auses or Latent syphilis are found in the higher age groups, and a larger proportion of the lower age-groups remain uninfected. The modo of trapsmission of eademdo syphilis in Bosnia his mostly non-veneral in charcter The runal population does not generally asociate the disease prith scrual contact, and endemic syphllos dous not

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·ENDEROLOGICAL ODRATON ahibit the epidemiological and other characteristics of a rocally scquired dear The no al cocamon utem and particularly of drtoklas ventes peared froca ponth to mouth (168 14.8), ocent opportunities for indirect trunnbeton of the infections pot. Added to the are other matisfactory conditions of senttattoo found to tafected village, which cplata tho fairty erto distribution of todemi syphill betwee the two rete O. MTS OF HOROLOUKAL ATNIATION (WALON KARO AND CONCHO NY AN-troum MA CALD OF TIATID LATEST SY HILL 7 Q m . 21 KU IL Ik 314 ma Dodo Endemic sypolis has all the characteristics of family dear.. Oo.co Htbus entered a family Infection boy often trummonited from one member to knother und the dmoltancom infection of momber of the Gandy onco non. A Rody of this type of codeonic syphilis wut modertaken in 642 lalected famille It observed that the lufaction-ruto moog children yurled according to the Infaction of the parenti, illustrated below ha dhe koch pit bacted Whend Hosted bad 31.6 92 K3 la at the familiar conted, the children done to bafected. Tho ocurace of infection in the children of balthy parents to tocounted for by the lat that the children are mos apored to bfection when playing Logether they therefore contrat wroction oottle that bomo od belog

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·CHAPTER 3 NATURAL COURSE OF EDERIC SYPHILAS Tbo wtural tono desde syphilis la Honka ettructed the attcotion of typollaborate Deay manipo From the boopression that cowo forms of sypolo appour moro frequenty then Obers of actual, the froncos cecdot wat drum by cho that the caderolo spoils of Bomia wa benima in mod of a dilecat kisd from sporndis veneral partit, with the Cathowing special characterias primary ledops abacat recoodury mramoon the sixt oyidense of betriebles personalized erathenuata nuo formata the site and mucous poembrass, or on the osteo-artidar mystem, tregon cardiovasculas formativenlent, ubes, or ganlyn abwest ud boulthy children born of orphillitio mother. Thanc obration readied to a Calciom absical comment which provoked for a long thuoc la both mational and foreign Heritare. Howerer us ferait of a Beld pervey of larve prospe of individual dinical tax arried out by 1934 nad 1935 by tko Zameb School of Pabic Health, with the Anandia) ustance of the Rockerhet Roundation, I was established that the mountatalions of cademloopbDus la Bora were actually so diferent from those of venerally saqed sypatis. Cardonacelar od Dearborial izvolvement do not The apparent adrece of artata spoplotos or form of ophanfocadas Contal medlemskons-or the combinatoo-mu pomaly do to the epickembological characterlatta of the dintre cad to cortidaracall Shetort The reasons for which codemic mpkills mus previously coaskere ut benlos de maty bo oglased in part by the prybolophaal reaction of the patients living in primitivo condition. Slope it bacoronto Infectious din leta todas the first case of anth and which arety Test ha a total boespacity for work, t u not considered to the population, actromed to Hirlas ander persone social and conduc condition, 10 bemoedsretto asit bi by people living under por dereiloped conde tlom. A derrottre gratum fudal bation or borrokromoot of the Euro DETToo yoo wool here a word koos por hologlal tect op persons with Hipher Art anndards and grattet social ed economio obligation When Aring Haddards born and didenent del end ecosoolo obligations de stored, what appeared to be the bealacharter of the thout Lutppar This bts become apparent la regions of Bomia beroladotria Daation to collective Erret me maly cestoy i suporad conditions mes the um popolatotho Syphittio parfextations with more pro Honesty do tukee my oorly are doy considered to the peopio va ·30 EPIDETIOLOGY AND CONTROL OF DEVIC MYTHILDS it into their own family The infection of parents by their childrto mod the appearanco of paimary lesions ut sometimes the result. The spread of infection in a family generally follows certain patterns although varations obviously cist. First, a husband with syphilis may Infect his wife, she infect the yomger children, and they in turn, trunsmit the disease to the older children secondly an infected mother may transmit the discar to the youngest child first, then to the father and Amally to the retaining members of the household or thirdly in families whero syphill is introduced by a child, it is usually fint trosmitted to the mother then to the older children, and lastly to the father However it is often Impossible to establish the order in which tho infection has been passed on, particularly when carly infectious symptoms appear smultaneously in RII, or in tho majority of the members of the family Whilo vescical acqubition of sporadic syphilis among married peoplo is facilitated by sexual activity this s not the case with codemic syphilis ln Bomle. Both husband and wife may bring enderoic syphillis into the marriage but, as the infection was often contracted in childhood, it is - ally in the lato or latent stage. Because the marital partners will orduaarlly bave had the infection for many year, the risk of vedercal transmition is considen bly diminbhed. The following tabulation illustrata the average infection-rutes of married couples it abould be noted that these are subject to many virua toos, depending principally on the duration of the lafection and on the type and amount of treatment receved. More Wife Infected Harband infectod Both pertpan Infocted 23 ·CHAPTER 3 NATURAL COURSE OF ENDEMIC SYPHILIS The stund como endendo syphila in Botole attracted the attention al syphilolophos oitoy pantypo. From the impression that certain forms of ypha pporr more frequeutly then abent, or not at all the froncos coctelo ne dra by Chict that the codemle ople of Bodola wu beolga diresu od alu dipercut kod from sporadio veneral rypbills, with the following special curacteristics primary lessons abocat secondary soprauts us the first entdence of infection repentized quantbemata rare manttu of the item and mucous manubrude, or of the ortoo-articular ter, freqocat cardiovascular favolvement, tabes, or paralysh absent md baulthy children both of syphilite motherThese observations rerolied la factors alcal concept which propelled for a loay time in both mtood und fordion Hterature. However i revolt of field marray of laro props of individual ctinical axes armed out in 1934 and 1935 by the Zagreb Scbool al Pablo Health, with tho Doandal adistance of tho Rockerather Foundation, it is atbilshed that the manifestation of enderalo syphills in Bosnia an actually ao dilercot from those of encroally aqdred syphilis. Curdon scolar end petrological tono recacat do occur The apparent absence of certain symptoms or forms of typhilks, including con sealal muulfestattoos-e the combination-nus primarily dao to the pidenndatopical churcteristics of the dease end to environmetal Luctor Tbo retrops for which codonk syphilita wu proslowly coordered as a benega di sesso may be explained la part by the poyebolopio truction of the patheon flying to primitiro cooditora. Stace It is a chronke tafectlom dbando bich b keldon the direct ante of death and whilch rurdly reratta In a total tocapacity for work, it is not conddered by the popolation, kobuttoned to Artes oder polonitve social and ecopoulo cooditions, lo bo morte do ust bs by people living onder moro developed condi tions. A destructivo gummu tom incial letton or foralrement of the ocotrul Dervo rytom would be a mord eerlour pathological det og persons with Wher Ante Stards as prestet wel od ccoooplo obliputioon Wbea thing woundards rio Lod discreet pocal and economio obligations Mamed, what appeared to bo the belga character of the decat dappeal. This has become oppureat la regions of Bosata where idonda Bastion ad collecthre Hylag ke pedaally croatbay troprosed condition kmont the rural population Syphilito munatations which rue promoney not be thy rekosty kte dar conddered by the people u.

·32 ODPOLOGY AND CONTROL OF EDELIC SYTHIS physical and prychological burden and 4 an obstede to the further cconomic and social advancement. It wu partly because eademlo typhllis was looked upon u benipa that it wus fent to be ia koe way different from spondíc venacal syphilik La fact, the nature of the clinical and pathological manifestations is smlar in both, and treatment with specific drugs has a similar influence the dulerence is rather in the attitude of the patients and in the natural courto of the disease as it is influenced by the carroomcat Our prezent knowledge of that course may bo cumminzed u follos. Early Infectious lados Primary lesiops uro wekdom observed in endemio syphills, but they do occur " Although their infrequent diagnosis might, in part, be attributable to the localization on parts of the body difficult to observe, this cannot cxplain the actual ranty of their occurrence in endemic syphilos, since Systems to clinical investigations in large population groups with a high Infoction-rato show primary lesions in less than 1 / of the early casa. Ad Identical situation cuts also in other countries where primitivo bypieno and living conditions favour a non-venereal transmition of treponema! tafections epidemiologically similar to codemic sypbills, mach us bejel and *Djovera" Toc possibility of repeated exposure to infectious material atainly cista in primitive environments, but it seldom leads to the transmision of treponema in tacha large numbers ou occan through the more intinito contact of mucous membranes when syphilly is acquired vetereally As have already doted, the common use of domestio utensils, particularly drinking vel, la Bosnta favourt tho transmission of treponemos la order to make a rough atimate of the number transmitted, drinking vessel, or * ibrik" (so ig. 8), was examined by darkfield microscopy shortly after being used by a person mifanog froso papolar lesions of tho mouth. Treponemes smllar in shape und movement to T pallldum were identie la very small number Repeated trapuntaton of small numbers of treponema probably also takes place in the other wual direct and lndirect contacts of everyday life. Occanonal transandssion of treponemes in Large Qumbers under special Cucomstanca muxt, however not be overlooked. Lo fact, whenever primary lasloos were found, the infection appeared to have been contracted under circumstances which would favour rich Inne mistion, u 10 primary lesions of the nippie where Infection of the mother bu taten place quantities of treponema bezas transmitted from large oral papular in the child to the mother a nipple (it 9 The repeated and long lasting direct contact to breast feedias obviously foolitate the entry of great numbers of treponemos into the tissue ·MATURAL WOOD OF LOAIC SHITLD The names the case in eademlouwalioco marital pertoes has infectious typertes le tons on the reproducthe orans Ratal batercounter the obrony more the porebdity of transmission of great number of tropocene Indeed, in todenok sypbibes, contagious symptoms ute och doouly located on the orpio 1od primary lessons located on the retuin het been obserred to result, particularty lo eodemks fodol treat anplo (rce to 10). The frogocacy of occurence pour lesions dependa mainly on the des of the looculom ud on the condition ander which the infection Fus By contracted. A typical primary lettoa mally develops after masto hoculation with trepoocoe-45, for bostance, L 1 chance of the apple or on the poolt. On the whole, bomeyer Veneral traddon is to ba tbe Boxoho cuvtroomeut. Conditions there arou the repoured transfer a mult maben otrepanema with resultboy ledom la tho oral redon, and the patholopleal titos reaction does not manifest itself at the stto of the boculation to the form of a primary lesion This is supported by the Botings of Abuba, by moustva poseta of rotondent to befel treposench, obuted primary lesions following coitadon of the Hp and, under considerably less favourable conditions al apoene, symptomers torection, that is to a eropodelity slone, teated to a limited member of cases thout the occoncoce of primary kation. Aplonal apartmeota lo pank cured out by Morgo ad later by Mapoteon, Eagle & Fiecachman, also confirm that mbeitnical tafection ac enfection to take place poder contain aperimental conditions. LA d.condo typila, the earty lafectious leloos te reoerally coanthemusta od can bezakta of the secondary type. They are ally localized pepolen, the aloumen a which, especially in the oru redon, and docplected und trotted, to coordeable all 11 13) Seres messbasd a family open exhibit belona identical to appal od location. It bom boto posudbike, in the Bosnien programe, to obrovo the dardlopment of the darse la come familjes from the Tory begnalog of the bufette persons bare been found to be clinically uod reroloplaally patir at the first cantanton la bot mbetet oomboos revelled * padal to the setologlalt with no poticeable lesions on the din of cool semble, a typical pepolar lesion fully appeared to the opropan Otha sintetthon Lute molestation of codepodle phite do dot dilar to those of poradio reperal sypbil's (see . 147). in pompie logance, beatgo Lato ledou me rather arting because of the end time destruction, per teulerty in reported chaood when octening ce conspicuos parts of tho body (reo y 10 Such fortes, bowcrat in patria by becoming must.

·34 PIDELDOLOGY AND CONTROL OF ENDEVIC SYPTUL Gummatous lesions appear most frequently on the skta, ia the oisopharyngeal region, and in the Osteo-articular system. Although frequent in children, they also occur in all age groups Affections of the bones and joints all for special attention, tome regions they appear in us many as 20/ of the cases, tho most frequent belog arthralgia and ostcoperyosotis (rec fig. 19). More than 80 / of the osteo-articular laion found in Bosnia were symptoms of late syphilir. The great majority of these were the result of syphilis acquired la infancy and not of congenital syphilus. The question of the involrement of the central nervous system in eodemlo typhilu long remained a major point of scientific interest, since it was muggested by Glock and his group 14, ILL, 17 that such involvement, especally that of the parenchymatou tisues, as in labes and paralyas, rarely if orer Occurred. Field investigations carried out in Bosna in 1934 and 1935 showed, however that all forms of neurosyphilis occur in eodemic syphilis, but that ałypical or stationery forms are frequently cocolatered. , # # Cardiovascular involvement is also rell koom in codemic-typhilis arcas, but no accurate investigations have so far been came out to deter mino the actual extent of its occurrence The ranty of congenital syphills is discussed in a subsequent section. Tertiary Ledon um Epidemiologtaal Index The occurrenco and frequency of tertiary symptoms vary with the treatment provided in different areas. Such vanations are described throughout the history of ryphiu, from the penod of the European pandemio up to the present time. If the feature of non-veneroal syphilis in various parts of the world today are compared with those appearing at the end of the 15th and the beginning of the 16th centunes, as well as in the 17th and 18th centunes when the disease wu codemsc la certata countries, tertiary tymptoms appear to have been very frequent when the discaso wau actively preading tertiary laions later became less frequent, although they will appear frequently in active endemto areas such as Bosnia. The early accounts of the disease during its activo periodi there suggest that as much u 50/ or more of all clinical manifestations observed were tertiary lesions. A similar dituation alsts today in rural foci of recent origin, while in aress wiero endemic syphills is on the wine the proportion of tertiary lesions i decreasing. In ach arcus the incidence of tertiary symptoms is no highet than that found 10 spordic van creal syphilis. Various attempts have been made to a plain why tertiary symptoms appear to have been frequent dunos those periods when syphilus mus spreading actively in Europe, and why on the other hand, they are relatively rare today in sporadze vezeical syphilis and to aplain why such lessons ·35 KATULAL OUT OF ADDIC A repain fregnent la acttre endearic-ypolls creu, ich us Bocal, where palmtttre living coodittoos al aast The adstoot of bobopally cauerent alms of treponemos dermato tropk or peurotrophe-with selective adotty to certain types of this, bus tot been concurely demontnted, nor i ft Hikely that sthnologia peculiarities to the box conat for ruslations in the OCC Teace of dideredt forms of typhlit. It is certain, horter that therapy play to toportant role, Rinco sequate toatmest of typhilis will protept the appear ance of terbary ind other late symptoms. In adequately treated case, treponemos remato to the human bort und may nooner or later become hattracted poder the influence of worlog copenic or endogenic factors This will give rise to pathological chaor lo to wretty allergic organden, reruhting to tertiary and other late wyphiinis manifestation. The indvenco of treatment, bowever ever only a portul aplanation, doce there and poomphical arcu in the world today with a bigh percentage of loudequately trated, or tres untreated, es dents syphilis where tertiary lesions are compuratively suit and no more frequent than in oras with sporadic EDCTED] typhillbo. It is important to beur in mind that, wherttu tertiary manifestations aro frequent in codemo areas, the reservoir of T polliton lumtyr extensive, u be shown by the autocou froh comes of early infection syphills that occer aod that tho permitiro litog conditions afford repeated opportunities for the perpetontion of the disco by direct and indirect contact many re 40 aldekº observed, to whics bero freth forections Ocean that formatous laukom may appar to some members of the bopgebold clther denit.nconly with, a pomo web ufter the apparence of pooptoor of earty Infectious syphilis to other Soperfection of an already biected Lod allanplo host by trupoosta to considered to be the chief reason for the large number of tertiary mm. fcruttona la actre codemio-syphil's wa In Creah rarul fod of eademis typluts were the bestial Infection takes place lo arly childhoodh, the mbrequent son courro olyphilis retult to tam nobtalogeal cheaper with an hered reactity of the orpion to further immedom of tropooemes. Little obtu to opposed to repeated inedion of a scoritized burda boste by trepoocma from the infected AUTTO Ddp so long u the potuoltre living conditions of the popolation remain coaterfally changed. In this condato a systematic emotiog and out on an entire umiy b of particulat hateret ( 21). The family condeed of siteen perron, all of whom proved dniany wod seroloputty sepatirs at the first cumloation, lactading the oldest soo (No. 5, who had received siruun tretet lot syphilis 18 year befon The Best control cumio thlon carried out 17 months later bormod that a fresh afecttoo bad developed in the fruity Euty Infections lesions or sppeared to three memben

·36
EDENOLOGY AND CONTRA OF ENDOC SYTHILI
Mo. 11 SULTANEOUS APPLARANCE OF SECONDARY AND TUTTARY
SYPHILIS NA PAMILY WITH AN ACTIVE FOCUI PINO DAKULD
Vieira
Ylila
To ng male and of
لي
ď
YILMO
لي
vinson
¢ ¢
XILIAI
0
Secondoy
O Tortlary sph
0 Anicety and aroganty neot
Berolotow improvement
Berologie in menord
Treba
(Nos 5 6, and 7) and sono months later seren noro were infected. At
the amo time the eldest son reacting differently from the rest of tho family
u i realt of his previous tofection, developed tertiary syphilis, ahorrios

·J7 MUATURAL OR OT ZDEC pimotots ledlot of the pharynx Ith thepoo destruction, and becamo Koloplety podtire (Kabin and Melokke (VIKR M) lo tootha finly (D 22, the father 17 yan old, had been treated for phillies with siren od bieth 10 yan prostorty His vifo had a stutto toamneis o syphile Aytematic cumloation ubored that the mother wd a 13-ar-old child both bad crty tafectious typhilus leskoos to the form of hypertrophic papula on the toogoo and tonsils the father on the other hand, bad Dodulo-oloerous picomata on the skin Lo the puteal rapon The chest chuid, 20 yan olup, as in the lateok mas HL COLDART AID TERTIAIT MIR IN A FAGLY WITH A T FOCOS QUO MICA) M Am noi 1 2 0 Utached The altention to this family must be interpreted u maantog that, whilla the mother and cor child had aarty infoctiora typhilia us a repult of fire Loculation with troposemes, the Ather who had been infected and loadequicy treated 10 years before, alubited tertiary symptoms becauro of ro-expoware and superinfection. The difference to the framuno bological facetvity or response to these persons was relected in the rerniting dinical mendation, Lou third family ( ) to of the memben (Nou 4 cod ) ahibited yaptoms of austy bafectious philis mattinonly whilo to other for 2 od 7) hed formatos dextruction of the time of the soft nod bard palata The Letter to veio the predmother, 37 yan a whore bittory showed that she had been tracted for Totila 50 yn before, 100 a young woo, 21 an old, treuted for onlymptoms of frenga utbe of 11 A farther compless tho case of a your wifo wbu dardloped pumata white ba baband derdloped early infections Recondary syphill. The 3

·38
ET DE LLOGY AND CONTROL OF ENDEAC STPOTI
possibility of the we i escaping Dew crpospre to treponeres under rock
circumstances is remote
Should living conditions improve and the chances for non-veneraal
transmision of treponemes decrease, or should treatment be given, tho
FIG. A TERTIARY SYPHILIS IN A FAMILY WITH A FRESH FOCUS (W10 TAPIA
57 yrs
11
24 m
21 m
Im als
Secondary rypto
Latent syphila
O Tertiary syphate
Unitated
oumber of Acw cases with activo tertiary lesion will dimialah ia adeundo
arcar. The relationship of Carly clintcal syphills to activo tatuary mant
festation has already been illustrated in several ways. Wo may mostrato
it further from the observations made in two villages where the locidence
of various forms of syphilia was recorded. In Kosona (fig. 24) a high
FIQ R. DISTRIBUTION OF BECONDARY AND TUNTIARY SYPUS ROBOVA)
ILS*
Sury
Typ
Hot Indebitants to
Gorputh SX

·39 u COOLSE O DOEIC STATE pronkoa of diseat us ford (236) and the reservoir of Infectlog nos atendre, or the tre found, 1736 vai arty tnfectious (accoadary), 609 % Tote batent seroposiths, while tertiary syphilis accounted for 21.8 Or thet 21.5 % 133/ bad tertiary optoms of recent date zod shoned on a tertiary ledom which had occurred some time before Thla represents, therefors, focus of eademic syphilis which bad perted for a comidarable time but whech nas spreading antirety Nomerous father ata of testing sypialis must be perted in this are M .. DUTRUTTOR OF DUTY AND TURTURY SYPHILA (oud Us T ILA Her mx A dietet uituation pronulled lo 810. 231. Hero the pooral lofaction nuto w abo comparatirely high but with a relatirely mal atabe of arty tafectious (nccondary) wyphbls aux (1.98. A Mery all paccatupo (29) of ww catat recent tertiary lasloos my found, whilo a much Weber perceatap (144) sbored me of old tertiary ledoar. The latter had derdloped wheo the cock focus had bere preding activity As the rearrot of treponemos pudott lestened, the pomibility of reareotlom uod fuperinfections dinobod, and tho gumber of are with fresh imary manifestations consequently deed. The pathogens of torary pypbitlis in rich cuts an beat be tatar preed on the bus of ropeated treponemal nido la atrendy custood allerk opakos. Considerable mopport for this found to the group Laboratory end othe tarestiptloos aarked out by Poger & Landstetoer Cheory Dom & Peares, Mamog od oben. There are botton un town that repertofection contato poco lo so zbready tafected host Asind, Rubrication roula bat pathological reaction to the readtrod bost with a derdlopact of the bato destructive type of syphilitio ledon

·38
ETDETOLOTY AND CONTROL OF ENDELIC SYPHILIS
possibility of the mos e kaplog non exposure to treponemes under ruch
circumstanca u remote.
Should livmg conditions improve and the chances for non-veneraal
transmision of treponemes decrease, or should treatment be given, the
FIO. 2. TERTIARY SYPHUS IN A FAMILY WITH A FRESH FOCUS ONO LAPUA
547
37 m
7
24
71
0
3
Soooodery spalis
Tortiery ryphants
Untuched
Letent types
number of new cases with active tertiary lalons will duninish in codemic
arcas. The relationship of early clinical syphilis to active tertiary mani
festations has already been illustrated in several maye We may illustrato
it further from the observations made in two villages where the locido.co
of various forms of syphilis was recorded, la Rosovi (fig. 24) a high
ne. N. DITINUTION OF SICONDARY AND TERTIARY SYPHUS KOSOVA
17
121
Tatry
hech
Nubhabitut 700
BeroperX

·41 MATULAL DO OT EXDIIC MTHILD atly decres with time. In addition, the filtelihood onfected woman trapamttting the disenx 10 bes odprlog will, 4s well koopt, deerensa with time and with the dumber of propanda. Since vezaul syphilis b brally contracted after the person boi tatoed maturity the Alkeilbood o coopental typhill to the children is condiderable for some time. In eodemle spis, however may rein penerally capss, la both mala und fetala, bet een the acquisition of Infection rpd the attainment of maturity the probablity of the mother's giving birth to compentaly mphithic children bs tbos reduced from the outs. Secondly the low gradards of hypitne of the population of codeonic-syphilh eus poeally retatt to a high neonatal-mortality rate. In the nurt ass of conpetutal myphils to a cheren, the life a pectancy is consequeatly further reduced, particularly if Uttle or no treatment is inilable Altboot Do Ixt dat can be given u to the actual loncidence of congenital syphills in Bomha, I must be expected to be relatively lofre qucnt14 An favestigation wi arried ou dortos the present cumpaip to determine wether the mother infected with codemi syphilis, would transroft treponemes through the placenta to the alpring. This was done by comparing infected cod pon-bofected groups of rotoen both of wboo lived under the name conditbons in en a wh an trerage Infoctionmito of 27% The results are tabotated below 141 in 797 134 25 213 775 1,611 Noottor of poten put Morbund Mop < dian la frutto la todo 103 21 042 HIS 6.3 30 (23% 11 073% 51 ( 2005 lo 42 bacudaro obremed, the station mu follom db subtboa buona 10 17 7 Tote 21 15 It let that there be byter nte al will boths la vomen tafected with endcrate types this is the son of diapltocutal infection. Altbough sono con oltal mobil pours, His reastrely sure to the bytoy child populuton The Woh penen Dopata mortality rate found to brands in this perticular region is a reaction of the ke sundards of byplane. This is ·40 EPIDE TOLOGY AND CONTROL OF ENDRIC SYPHILIS Wher, therefore, a host which is already in a stage of late or latent typhili I reafected, no prmary or secondary lesions will result however Iction of the tertiary type, accompanied by rapid tissue destruction, may appear It is likely that a similar situation also crists in other treponemal diseases, kuch as bejd and yah. Laboratory aparents bave shown that reinfection may result with out lesions developing at the actual site of inoculation hand that asymptomatic infection may occur , Magnuson & Rosenau bavo thed to analyse this type of relative immunity by determiniog quantitatively the number of treponemes which will bring about renfection under controlled conditions. They conclude that, which afymptomatic ruinfection occur, this indicates that a partial immunity alas sufficient to destroy the majority of the treponemes and to prevent a lesion from developios at the site of the inoculation, but not miildent to destroy all the treponemoc which will continue to penetrate into the hont. These asperiments havo shown that this modified reactivity lo the host may partiet even if treponemos do not survive in the body after infection." Thus tertury lesions may develop for one of tiro reason. First that may be reactivation of residual treponema is a seasided allergio organism, apsetting the parasite-host relationship This oocun In ontranted or inadequately treated sporadic venereal syphilis it may also occur 10 endemic areas, usually in the stationary or regresave period, but it is probably of secondary importance. Secondly tertiary lesions may develop from superinfection of the host which is already in an allergic state as a result of prior infection. In such cases, any residual dormant treponemes in the host aro Lidly to be of little importance the essential features are the host s changed reactivity and allergic gate. From the observations made and the results of the campaign In Bomnia, We may conclude that it is largely doc to tho environmental factors which influence the natural course of the disease in endemic areas, and which are the chief ause of reinfection and superinfection, that the late mantfestations of syphilis appear cariy particularly tertiary kesdons in already tensitized bosti, and that the frequency with which ach lesions occur represents an epidemiological indication or index of the state of activity of the rural eodemnic foci, and of whether their origin u more or less receot. Rarity of Cappottal Syphilis It was previously thought that the non-occurrence of congenital syphilis was one of the characteristia of codemic syphius The following faces, which are consequent upon the epidemiological and cavironmental condderations we have already advanced, help to coddate this problem. First, in untreated, and cren more so in treated, syphilis the infectiousnos gradi ·CHARTE. ORGANIZATION OF THE FIELD CANPAIGN AGAINST ENDEDOC SYPHILIS In orputin any max au paig paint codemis syphilis, or a plast any other treponemal disease with similar epidemiological features, toch us bald down witch talo beld or ym, methods of procedure should Ant Into account the characterialas of the confrontent and the particolar cpldendological features of the doors uning from it" The present propremno in Bosnia w begun in 1941, and the following criteria ac adopted for the Beld campaign uit proceeded from district to district, lod will coothupe to be bed until the end of the promimme L. Coro-iloding bould be corded out by tematic rerological crecolog of tho coture population in addition to clinical Inspection 2 Adequate free treatment should bo provided for all demoned cure of codemlo syphilis and should be obligatory 3. Follow-up re-eammation of Infected areas abould not be confined to the aura dagored and treated during the initial party but would also Include rcumination of the remainder of the population & Lotervek, util i Atisectory epidemiological dtuation has been established and consolidation of the results has been achtered through the regular publie bealth cryicet 4. Data should be recorded lod control and follow-up measures established on a family basis, and the Individual cards of infcotad persons abould be an Internal part of the ſumily record snor the family is the busto nochalas well as epidendological unit in Bounla illected by codonk typhilik S The active collaboration of the population in cestrylog out tho promume should bo recunod, latcrant In bealth work would bo simulated, ind bealth cooxcloumes should be ckrdloped us part of mort peneral dfort to improro Arlog coadroas ln rural areas 6. The methods and the public health principle appiled should be Llar throapbod the areas in which the programme belos curried out, Thrto Beld proaps, or tam, were originally orptired, auch belar composed of from dght to ton member of the national medial od mallary Rut. The lam lenders wat apable medial workers with fruly estento pericoce in specialized lostlotions mod la the Hold. The tems did not to bene a medical oficer attacbed, but the wopertion of the batth otice of the district in which the tam tatione nuured in order - 43 - ·42 EPDDELIHOLOGY AND CONTROL OF ENDEAC STTHIL Illustrated by the following figures, showmg the mortality among 200 iofuots born of mfected and healthy mothers fort theyt ( by Mort Jnfants murviving Doro then one Infants dytos befaro ano e 739 26.1 JL. Thus tho mortality-rato among chídren under one year of 10 bom of Infected mothers in 57/ higher than among children of healthy mother It will also be keen that loss of infuat lives due to syphilis es relatively mall, aod consequently the proportionate mortality from congenital syphilis may hardly be noticed despite the high endemm.c-syphilis infoction-nata. It is a strikdog feature of the crrvironmental conditions that the high infant mortality rato is somewhat compensated for by a high birth-rate. During tho present study it was found that infected mothers had an avera of 9 1 pregnanas up to the ape of 45 whereas healthy mothers had 10 averago of 8.8. This difference was balanced by the difference in mortality, and survival-rates of children to both groups fast mennoned. It might have been expected that regions with the highest prevalence of cademic syphilis would also show the lowest birth-rate, the highest mfant mortality-rate and the smallest increase in population but, although it may appear paradoxical, the highest birth-rate and the most marked population increase there often found in the most highly infected areas. The explana tion for this may be on the ono hand, that in the most highly infec ted areas conditions art very primitive and little or no restraint b 2550 cated with sexual life, with the result that conceptions are frequent and, on the other hand, that, sioce the infection is generally acquired in child hood, the out of diaplacental transmisson of treponemas is considerably reduced.

·CLA TELL ORGANIZATION OF THE FIELD CAMPAIGN AGAINST INDIVIC SYPHILIS In orpantring any ma cumpaigo paminst eademic typhilis, or apimt iny other trepoomuldsete with similar epidemiological features, rochu beld or ym, methods of procedure goald Bird be bold down wilch tako into account the characteriales of the wytrontsent nd the particular epidemiological feature of tho dine widos from It" The present promume la Botola was began in 1944, and the following aiteria odopted for the field campaigo us it proceeded from district to district, and will contmpe to be the outil the end of the programme 1 Custoding should bo carried out by ty temat «rological retcntos of the mattre population to bolo to clinical Inspection 2 Adequate froo treatment should bo provided for all dha gooned cho al codemio syphills and would be obilatory 3. Follow-oproemfortion of Infected urtu bould not be confined to the case diagnosed and treated during the initial prvey but should also foodor-cambiation of the stmarder of the population et laternak, lootul a Abufactory epidemiological stortion has been established and consolidation of the results has been achieved through the repolar pablic balth service 4 Data should be recorded and control and follow-ap masures established on a fumity be, od the individual aards of infected persons bould bo s Integral part of the fondly record since the fasilly by the bado modal dl u pidemiological unit in Bomla afected by codemalo syphin. 3 Tho uctive collaboration of the population la canging out the propuno should be secured, fatetat in bealth work abomid bo Almalabedi and bealth condonane sborild bo derdloped u part of moto penal dtort to improve firing conditions in ranl wat & The methods and the pabilo bealth polosiples applied would be sudlar throagost tho was lo which the prognatome b being carried out. Thrte Held groepe o tem, were originally organized, each belas composed of from dght to the members of the national medical ad molary Hur The lam laders most capable medical rorkans with frity extelo expericace to specialized Insulations and to the bed. Tho tam da pot my heart i medical otiott Attached, but the co-operation of tbe health quicer of the district in which the tam u ratione mu tocurats ander ·44 EPIDEIOLOGY AND CONTROL OF ENDEVIC SOLD to provide adequate medical mapendon. The investigation and study of spidemiological and clinical pooblemi, in particular the trse of penicima in endemic typhills, and the central technical fupervision of the team were the responsibility of the syphilologist la charge of the central dopeo ry from which the campaign was directed. Each team had I serological field-laboratory at its disposal, manned by responsible technicians practised in carrying out stodiagnostic tests for syphilis. Qualitadre Kaho and Mencke (MER I) tests were carried out on all blood samples. It was not possible to perform quantitative as well as qualitative tests in all parts of the field quantitative tests were therefore confined to specual plot, research, or control areas. The average testing capacity of a Beld laboratory Amounted to approximately 600 serological tests a day Each team was made responsible for a district at a time. There was 40 average population of 30 000 to 40 000 lohabitants in each of the 19 die tricts so cumined up to tho end of 1951 The districts are divided into mmaller administrative unit (MNO), cach having approximately 8 to 10 villages and 2,500 to 3,500 inhabitants Each team had field cars at its duposal which would take the team members from their beadquarters to auxiliary sub-units or as was MOTO frequently the case, team members would have to walk for several bount through mountainous country to the hamlet in which a working base was established. Teams would generally be divided two team members working in cach villagt. Fidd facibnet would be improvised at a community centre or in a suitable bouxe or but. The inbabitants had always been informed in advance dther by the patiopal authorities, through existing local organizations, or in preliminary conferences, of the purpose of the work. This type of health education proved very valuable. The blood amplas collected during the day were canned by special courier to pathering points by the road where a car would take them to the laboratory for examination. Blood Rumptes always reached the laboratory on the day tbey were dram 10d, even dung hot fummer months, haemolysis was very rarely observed. Al cases of syphilis detected dinrally were treated immediately On the basis of serological cuminations arried out on the entire population in the area, treatment was also given to those persons with positive serological reactions. Six to aght days were usually required to cumine systemikally the population of each administrative unit (MNO), while the time devoted to treatment wsied according the schedule used. A family record wu made of all infoted families found in the villages this included the lodividual card of each infected member of the family together with a record of all clinical and scrologial euminations, crestineol, control aaminations, and any other relevant matalal The record system ased for the rygematic serological aimination of the entire population in ·45 ORGANIZATION OF THE FIELD CAMPAIGN the villapud punomodtog turut bered on the latest correy data (1949) A toy maluchle record of the infected lumia wus thus coartitutod wibost the Information no patistical toal of the data could be possible. In the laps there were really do hooga more than half an hour : salk from the piece of relation. Although treatment nas obligatory for persons found to be infected, the degree of voluntary co-operation w hipb and, with very few exceptions, no compardon proved Detary The tam members reumatoed in the village or u idd station will matematu aumination had beco completed and treatment pren. This had * Suporable peyebaloglal eest on the Inhabitants. In addition, Hoco there were Do it working hours for the tam or clinic hours for the POLAN, they could be tramined and receive inyections all through the day thus rodering way Interrapion of their agricultural or other work unneces. Ary This mouent remulted in a pood response to the promamme As the people for the res the numerous anses which were cflectively belped, lacreados support us stres to the campaign. Follow-up cumint toon could consequently be carried out with les dificulty and more rapidly than had sometimes proved to be the case in the initial survey and cumi- Betloss. A diagons of typhlils was established on the basis of amnestic data and dimical Lod scrological boding. The epidemiologial station was taten Into account in cases of doubtru scrological reaction with do dinal Agnus of history of typhilit. If such reactions remulaod mochinged or became pronger on the brat follow-up cumination, this mus considered yptocutio of syplutis la familles whert ooo or more of the other member und & coadrmod dupotis of the dar During the faithal period of the campaign, the percentope of the popu lation camiced wurdathredy mal. Lato us the rear pained experience, 13/ of the cool costos population rus serologically cuanloed during the Arst visit of the team durlog the pebrequent control cumloations this proportion stocranxed to approximately 95%. Thus, in familias bere satire Infoctions were found, only og fart occadons would a member of the family fall to be caumloed 4 000 time of tooth The tal proportion of the population witch Acaped the chointing contrsted moul of persons who had bees brcut from their homes for LOCO time or a very young children to balthy familia Under the upcult condition of the Weld work, it mu fotoctimes dot easy to obtain Wood Hooples from your children. The prezenbed perdita trentocut wui com. pleted a mon 100 / of the cutes. This teet should be compured with the Kostkactory reset of prerious efforts with when od bituruth when only some 15 % or 20 / completed their treatment At the start of the temple the tempo, aprened to the wount of frowed corred, much more supld the later on, saco the bus tams bsd to return to reploas pretiosły oed laarder to carry out control ·46 EPDENOLOGY AND CONTROL OF ENDDIC SYPHILI axaminations As the number of areas examined increased, the rate of attendon to now regions decreased. From the beginning of the campaign at the end of 1948 up to the end of 1951 systematic caminations and treatment of endemic syphilis were carried out in 19 districts, the teams completlag work in one district before moving to another Some 438,863 scrological screening cuminations and 113 158 scrological control caminations, or a total of 552,021 blood tests, were carried out by the field laboratoria Drinng this period, 35,238 causes of syphilla weto diagnosed and received treatment, corresponding to 8.1 / of the population camloed. The following tabulation illustrates the distribution of the different stages of syphilly found XO Early Infoctors londons and primary Congenital Latent Late 3472 1 29 681 1,928 971 022 24.. 547 Toal 33,238 100 Thero was considerablo variation in the prevalence of disease from district to district, it ranging from less than 1/ to 13/ or more. In como Smaler adminiprative units and villages, it was often found to be constderably higher The average infection rate of 81/ therefore dow Dot Givo a true picture of the distribution. The relevant data on this point will be found in the section dealing with the epidemiology of endemic syphilis As the highest infection-rate was found in north-eastern Bosnia (sec fig. 4) tho most intensive field work was done to that region. In cassing the Importance of the disease in the different areas, consideration mu gaven Dot only to its general prevalence but particularly to the proportion of carly infectiow cases, stice that is an indication of the degree of activity of the endemxc focus. Thus, in the district of Lopars, with an avenge infection-rate of 1237 only 67/ of the total number of infectious casos were in the early infectious stage while in the district of Tudo, whero only 6.3 / of the populadon was infected, the percentage of early infectious asa was II 4 The mort extendvo reservoir of infection was found in the district of Gračania, where as many as 424 / of the total number of infected cases had early infectious lesions. la Telao and Gradačac the figures were 13.8 / and &8 / respectively The lowest rates were found in the districts of Visoko and Zenics, with 13 / and 19 / of infectious lesions, respectively The proportion of fresh cases of syphilis consultotes an important epidemiological indication as it expresses the extent of the pool of immediato ·OLDALUZATION OF THE MELD CATCAION 47 Infoction toom to putimalar ya. Priority u therdore free to the present atpaign to action to use with the highest proportion of certy ledoos, where the initial tak mu to control the further spread of Infection from each setire fod in the shortest porable time sod, I poolbla, to dimtoate thon completely I be obrloos that this is more important in A pablo-health programme than to begin work to us where the codemlo #utlocry or receding The tak o redoding the leterror of potential lato manifestations of syphilis by traadag late Latent chabol wocondary Importance to the total phase of the campaign when areas are selected for ·CHAPTER 7 TREATMENT OF ENDEMIC SYPHILIS WITH PAM AND SCHEDULES EMIPLOYED In the campaign against endemio syphilis, the use of procaine penicillin in oil with 2 / aluminınm monostearate (PAM) proved decidive in solving this health problem. PAM was used regardless of the stage of the disease and its value in the treatment of syphilis, in view of its pop-toxicity its rapid effect, the short period of treatment and the faality of administration, was confirmed dunng the present field campaign Combined penicilia and arsenic treatment was got used, Darias the Inital stages of the campaign, however some groups of patients were treated with PAM combined with bismuth. Subsequent control studies of these groups indicated that the results were not different from those obtained with PAM alone. The combined treatment regimen was therefore soon abandoned, and PAM alono was mubsequently used. The treatment schedule used for adults was 3 600 000 to 4,200 000 units, given to atx or seven injections of 600,000 units of PAM administered daily or every second day More recently investigations have been carried out in bmited areas in the use of a smaller number of injection In two administrative areas the treatment was a single injection of PAM, one group receiving 1 500 000 units and another 3 600 000 units tho will be dealt with in greater detall when clinical and wrological results are considered. The criteria for re-treatment were as follows (1) clinical grounds clinical relapse or reinfection (2) scrological grounds (a) petosteni poddve reaction to serological test for syphilis (STS) at re-examination 8 to 12 months after initial treatmeot (b) increased STS titre on te-examination (c) negative STS titre becoming positive. The ro-treatment schedulo ured was usually identical with the origioal treatment schedule, except when a subsequent control uninston showed scroresigance. The umount of PAM mi then IDcTeased by other half or an entire dose up to a total of 7,200 000 units had apphed in a shorter period of time (five days) Thero come variation in the treatment depending on the todividual case. TPAN U ont des proped by the World Hd Option - 48 - ·TATUIT WITH PAX Pendida muid tolented, and evta serated donde o cometimes Hesla doda tajertion Mate Hashetmer reactions were occdonally obremedha partidarly in fresh any of syphilos lo come low coses unlarla developed. There me, however no face where treatment was inter rupted because of non-tolonne or because teactions were too marted. The nhuo of penicillinas derdomsented in the Bomian campadashould bo considered from the polnt of view both of the clinical od scrologlal results and of the policem otopical resulta KL. 1. MULTI OP PAN THERAPY WITH UNITI onto pRO C YIL Y 11 1 unir D Y 1953 0 for who Lorem Chody od reach the Current Trade Cu Serologie Robe The aurty clinlal symptoms ladatot ophalis dappeared u rapidly ular tratocat vith PAS tacy do lo sporadio repaul typhli. No arro of code to typhilis in the earty di daro was encounteed which did DOT retpood figurably to treat ocot. The dardlopaent of pumaton lasloos mu mpidly crested and, if the destruction ws Dot too ninced before treatmcut mbegon, restoration of the united function procally followed. An aceptional con that of a young female #bo had many fummata on the sklo od in the osteoarticular system and wo did oot respond to to cerated domma med iepakte bojections of PAM. On the xbole, osteo-articular lesionesponded well to PAM treatncot, diboogh cruha lezlons (bydrutrus od Turbom dattractive letion of the osteo tricolor topa) ho required orthopedic rehabilitoa mcthod.

·DECOLOGY AND CONTROL OF ENDEAC SYPHILIS Fru. IT RESULTS OF PAN THERAPY WITH UNITI ONO ARENA A VIL 10 B IV 151 وهل $ C L182 do o , ل O Gerologie optor Serologlaltie nchind decondary syphile 0 Tertiary with 1) Later typhila Chically and stological nett Arthralgic paint responded well to PAM in carly u well u in late syphilis. Cephalalgia and some symptoms no doubt arising from involveoxot of the oervous synem improved rapidly uod often deappeared completely The serological raponto to PAM us to other cotlsyphilis drugs, depends primarily on the duration of the infection. Inevaluating both tho werological and the clinical results, the sono prepło has been taken as a basis, that is, the results have been evaluated primarily lo terms of the family unit, the household, and the community rather than of the infected person individually This approach prondes an opportunity to Audy the problems of relapse, fedfection, and sero resistance, the saloo of abortive treatment, Add to on-matters which the custing literature has bo far not puficiently dealt with in terms of the femily ·NATDOT WITH PAX $1 We muy cite the followtay cumpla to ahor bor the diato PAM treat ment bday reflected in the tota inting on member of familia Tho most nopely destinuo serologtaal titra were found to families with sypbaltio Infections of roooot data. In one fumily of fire, at, from the prandather to the modeons, pero syphilfts, with secondary syroptoms and podtivo xrolophaal reaction. The entire family as treated dmultancourly with PAN In soglo doves of 600,000 bolts ereny recond day up to a toul ar 3,600,000 units anch, the children, BOTTETET belog grez amuller dore A kala al control remonttions those that three member of the famly werd merologlaly deputtre atter 6 months, four ter 20 mooth, and the wholo fintly after 77 month In another mity of members, the mother mod eklegt deaghter med In the latest sans with strongly positive feraloglal ractions, and the other Sonnt members in the secondary rin Tbo treatment schedulo employed constated of mentafections of 600,000 units of PAM for adults tho didest M. ALTE OF PATHR WITH DEDIT SCHDOLL CURATO VCD YILI . VIL 1151 Het (L200,000 1 100.000 lo 1,000,000 3.000 13. IH Ilm.co MI 30.000 ·52 EPIDEGOLDOY AND CONTROL OF ENDEVOC ELS daughter aged 23, and the boy aged 18 were given in addition, 10 ml of bismuth subsalicylate (10 / emuluoD) At the first follow-up examination, tea months after treatment, the family was dioically and sorologically Depairyo with the exception of the cidat daughter and her 6-year-old tister both of whom showed serological improvement Purther examination 15 od 24 months after the original treatment showed the whole fumily to be negative. La this particular family latent syphilis responded us well to treatment as did tho carly secondary cises. The infection was probably introduced into the family a short time before treatment started, and it is therefore likely that these were early latent cases In a third family (ig 26) there were three cases of latent syphilus. Too Gerological titro had decreased gradually 10 and 16 months after treatmedt. In No 1 it fell from 16 Kabo units to & and finally to 4 h No 2 from 256 units to 8 after which the findings became negative in No 3 from 128 to 8 The father and the ddest child (No 3) were re-treated with the same donge And, when the control examination was carried out after a further eight month, or 24 months after treatment had been beguo waldy positivo reactions were found in the eldest child, while the other had ul becomo negative. lo a further family (6g27) all twelve members were infected with syphilis, but of different stages. After treatment with 4,200,000 vmbs of PAM the entire family became aliancally and serologically negativt, Inclodiog those in the secondary and latent sages (probably early latent) with the ciception of the oldest member of the familly (No 1), ugod 66 who had tertiary syphilis. The gumman healed completely after treatment, but the scrological findings remained positivo even after repeated treat ment, as is often tho case in lato forms of syphilis of long duration The use of different treatment-schedules but approulmately the Amo amount of penicillin (3 609,000 to 4,200 000 units given over dillercat periods of timo up to 13 days) showed no significant differenco in tho results An interesting examplo us given in fig. 28. A fresh case of endemic syphilis was latroduced into the family to the infection was pubsequently trat mitted to the whole household. Duifercat schedules of treatment were used, tho watual total dose being 3 600 000 units. When the control oromination mus carried out one year later all members were found to be clinically and stologically negative, irrespective of the schedule of treatment employed It was noted during the campaign that, mth a total domage of 3 600 000 to 4,203,000 ooits, no differences occurred whether the doso was given lo sogle lajections in three injections of 1,200,000 units och on the first, second, and fifth days, or in ax or seven injections of 600,000 units daily or cvery second day Io choosing the treatment schedule to do adopted account you takeo of tho topographical difficulties in the areas aamined and of the oumber of cases found. The schedulo osed at tho beginolog ·TREATMENT WITH PAY m.. MALTI OF PAI THDAY WITH A RECTION OF IN DAT Ouro MCI A וחוץ LN52 T a é do og from che rotoploh Tree of the ampang Dually cooked of a large number of injections, and tbo tom meroben rould way in the 1dd for some time, itmainios is direct contact with the population Later doring the control almida tion, the number of lajections, and therefore the duration of treatment, wa redoced, although the total dongo of PAM remained unchanged. In one of teroristics, larper doto of PAM wu piren over. shorter period of time, buly thrco Injections of 2,400,000 watts on the first, third, und ihh dry in many instances considerablo karological buprovement of patirt serological reactions repulted i to dght months bater Tbo oppilation of such a douro certainly add to the doration of the electtre concestrution of penicillin to the blood comidered reces ery to the treatment or arty sphith (003 units per m.) Homover It un bot yet know what coocentrulog a pealdilla i Docentury La tho body thume, or for bow loor, In order to sbloro a complete therapeutic droct on reddeal trepone. The aperience alood to the Bountan propremton supports the view that per dones of repository penicilin should be pirea ovat i bort period ather than omallet dona ove longer parlod lt nu ocionally imposible to administer the routloo mbetul, ond the total doupe of Palm thai giren to u dogle injection At the follor spasminations, ibe Temu ho those are were found to ·54 EPDENOLOGY AND CONTROL OF ENDEAC SYPHIN be in no wry infenor to those obtained with other treatment chedeler This preliminary observation tends to confirm the view of Thomas and his collaborators Hand of many others 44.1 u to the high proportion of cures in early syphilis that can be achleved with a doglc injection of PAM 70... RESULTS OF PAK THERAPY WITH BINOLE INJECTION OF ONT NO BUCEOKA) A V 1951 2 3 B L 1952 ! ! ! no Secondary myphila rent syphile Cuecally and wrologlaly matte Truth In order to carmine the matter further an investigation mus arried out on two groups of cases. One group consisted of 110 causes of syphilis, of which 31 were in the carly infection stage, 70 to the latent stage, and 9 in the tertiary stage. The treatment plven was 12 ml of PAM totalling 3 600,000 units, 6 ml in the glutadi on each side. At the same time abortivo treatment was given to members of families who were likely to become exposed to the infection but who had no symptoms of syphills at the time of the cumination. This was done in order to avoid the risk of reinfectioa which would have prevented curto evaluation of the results. The first control cuminations were carried out eight months after treatment Fig. 23 and 30 show tiro families in this group, before and after treatment. The rquits spark for themselves, ·35 TEATED WITH PAR Tbo sccond proup of course thored only a few ba nfection. OY 156 ases, 9 rete secondary 136 latent, and 11 tertiary The group mu Arto a gomila doar o PAM than the birth, receives 1,500,000 volta la u dngle to jection. In addition, children who might be aposed to Infection we giren aborttrt treatment. The number of patienu treated b smal, but the followmy tabobation pivo u Indiation of the serplogical rohlta 24 months after tratment Lerarepthre Improved 2 121 10 s Toul 9 185 The Bomlan promrmde hus uorded only hated apcrience to the kc of the injections of PAM ), albough it is too soon to dow 109 definito condusions, the reports observed so fu ad Dot Inferior to those obiniaed ulter to run with a larger number of infections, crewbers the total dongo fa reduced to 1,500,000 units of PAM. The followiot loformation may sire a cartr pletter of the total royotu obtained in the treatmeot of codemio syphills with PAM In the administritive unit of Srebreman ta the district of Gradadas, were there was a prenience of 21.8 los control examinations were arried out over a period of 3 months on 43 comes out of a toul tumber of 50% origlaally cumlocd, or 7.2/cach of which had received 4,200,000 PN. MULTE I MONTH AFTER PAN THOLAFY WH antou niCTIOR OF NUNTI QUO FUCIKA tarit Tyth 1 Owls ·S6 RIDE TOLOGY AND CONTROL OF ENDEDAC SYTELN units of PAM in Leven injections 102 of these were also of early typhilis 307 were in the late latent stage, and 34 had tertiary typhilis Fig. 31 gives the total dinkcal and serological retulus of this first group which are considered highly satisfactory The clinical manifestations responded as well to this schedule of treatment as they did to the more protracted xbedula Fig. 32 gives detalls of the serological finding in Srebrenica 36 months after treatment. The best results were achieved in secondary syphills, wbero 841 / becamo saonegative. During the two follow up exam tions, 145/ of the patients were re-treated mith the same dose of PAM. 710. 12. RESULTS * MONTHS AFTER PAN THTHAPY WITH A UNITA I T SECTIONI OUNO SRDRERIT 777 Albornom the ܒܥܥܕܕܪ Lo MI Eaty Kuwe Site IR Late Lates ܥܢܥܠܪ » Tatry 1 27 34 ANTI Berologically non Serokogled the mchanged pretty Borotoplica benepromament Serologia re than Teolak, in the district of Lopars, was an old receding endemto focus with 4 198 inhabitants 721 causes of syphits were dus grosed, 17 of which showed symptoms of early syphilis. The treatment schedule osed Pras 3,600,000 to 4,200 000 units of PAM When the control cumination was aimed out three years later 76 6/ of all treated cases bad become seronegative. Re-treatment was arried out in 261/ of the cases. It is difficult to a tablish the best moment for re-treatment, cicept 1 cases of clinical and scrological relapse, or in troresistant auses of early syphilis When serological findings remain positive or decrease losignificantly after an adequate dosage of pedrallin, it is not yet know for bow long re-treatment con be delayed in individual wires without fara to the patient.

·57 TUATION WITH PAX In man citopeloos the qucption b eres more complicated doce there my be no permanem frottle for periodic tamiration at thort internet of the cases found dwing the nitial parvey Control andoutons are ally arried out a furh long bisnis, and destrog na to whether retreatment is recetary has to be made bronnectutety La tbe Roselas company was stuully decided to the re-trealmeat to ans, especially thont of auty sypkih, voice ander other artikanca mod petely bare beta kept més obnormation. In the bort dosely superiod control Kres, bowever the station Wu disertat. Thos, in obe administrative pont, la tha district of Zrornik, wae thee van 22 cases of photos bad freza condary lesions, and no re-tretinent motiven for 24 months Al cx Wet otipoally prea loul dosage of 3,000,000 units of PAM to s Lojections Family contacts, represcoting 11% of the infected at were also treated with the woo come. This proportion Carterpoods approad. Dately to the number of a butty re-treated. A control auntation Bode two youn after treatment whered the folowing onlogical and IO (2 445 135 Werontpath Eorprenad No de karolopar roup 17 Total 100 100 The results do pox aufer miraty frota thone obtained to varla of patients were re-treatment had been prel It would toen, therefort, that it-testocat may be detayed in certain proaps Control mlnations, boucler should take place at faternais considerably shorter than to rout so that breth ousa w Dot brooche Tod for the Cariber spread of to ftctlog to the ata od book are world be detected od treated us aly a poutta The maimedute epidemiologlal results which may be expectod utter the blue camination and treatment of endndo syphi ha mo ampai depend on aver factors, the mor troporteat of which on (i) the pred nd completrees with which the ystematic amb Vies of ibe population up the treatment of Lafected ass uod fumtly contacto tre carried out, m) the extent of the terror of Infectionnets at the beginning of the aumpaign Lod of the inde arah unter imbl treutanat mod Mbront of popolatos morements within our ira and koos adlighboudig en ·58 EPIDEMIOLOGY AND CONTROL OF ENDEAC SYTULIS When these factors are favourable eod tend to restrict the disease, e loag interval between the initial and the follow-up examinations may stil allow of good results. But in circumstances favouring the spread of the disease, and where there is an extensive reservoir of Infection, sathafuctory results cannot be expected. Epidemiologtaal Results and the Necessity of Abortire Treatment of Contacts Although the Bosnian campaign is not yet completed and data are bot yet available for the entire vrea, it is neverthclass possible to give some indication of the type of epidemiological results which can be achieved. In addition to the comple already given, he may mention the systemato campaign carried out in the district of Loparo from the end of February to May 1949 during which 3,269 cases of syphilis prete dixcovered and treated, a prevalence of 123% of the infected cases, 221 showed symptoms of carly infectious syphilis When the first follow up examination was carned out 14 months later 35 cases of early infectious syphils were found, of which 32 were new and 3 were relapses or reinfections. Thus, corttaglous manifestations of syphilis had been reduced by 84.27The treat ment was 4,200,000 units of PAM Family contacts were not treated at the time So far as the 32 new cases of syphilts were concerned, 37.5 / came from families in which there were already infections, whlic the other 625 / wcro members of familles where ao cases of syphilis bad been detected 14 months previously It is obvious, therefore, that when follow-up examinstions aro carried out, especially in areas where there are actively expandios focs, every effort must bo made to discover the Dew sources of infection, not just among those previously treated but among the catire popals don of the area. When the campaign started, it was believed that the chief risk in perpetuating tho disease camo from Infectious relapses in Cases where treatment had failed. It became evideot, however that the important potential sources of infection were represented by infected per sons who remained untreated through being absent or otherwise excaping armigation by DC# cases of sypbills imported from other areas us a result of populauon movements, and particularly by symptomless coses in the incubation period at the time of the original examination la pbich infectious lesions subsequently doveloped. The geographral detribution of secondary syphilis in the administrative units of the district of Lopare, before end after the systematic field campaign, is given in fig. 33 A second control examination of the tire popplarion is being carried out at the time of writiog, three years after the start of the campaign and 22 months after the first control examins tion, at which umc abortive treatment was given to all contacts in familles where fresh cases of syphilis had occurred and 237 / of the cases received

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·58 EDEDOLOGY AND CONTROL OF ENDOLIC SYTHILI When these factors are favourable and tend to restrict the diseases, a long loterval between the initial and the follow up examinations may si allow of good results. But in arcumstances favouring the spread of the disease, and where there is an extcosto reservoir of infection, muisfactory results cannot be expected Epildevalological Reset to the Necedity of Aborthe Treatment of Contacts Although the Bosnian campaign is not yet completed and data and got yet availablo for the entire ures, it is nevertheless possible to give somo indication of the type of cpidemiological results which an be achieved. In addition to the examplo already given wo may mention the systematto campaign carried out in the district of Lopure from the end of February to May 1949 during which 3,269 cases of syphiles were discovered and treated, a prevalence of 12.5% of the infected cores, 221 showed symptoms of early infectious syphilis. When the first follow-up examination was carried out 14 months late 35 cases of early mlectiow syphilo nero foned, of which 32 were new and 3 were relapses or reinfections. Thus, contagious manifestations of typhilis had been reduced by 84.2 4 The treat ment wax 4,200 000 units of PAM Family contacts were not treated at the tme. So far as the 32 nepr cases of sypbills prero concerned, 37.5 / camo from families in thumb there were already infections, while the orbes LS / word members of families whero no causes of syphilis had been detected 14 months previously It is obvlous, therefore, that when follow-up camina tions are carried out, aspecially in areas where there are actively expanding foci, every dffort must be made to discover the new source of infection Dot just among those previously treated but among the entire popola tion of the arts. When the campaign started, it was believed that the chief risk in perpetuating the disease caune from infectious relapses in cases where treatment had failed. It became evident, however that the Laporteat potential source of infection were represented by infected per son who remained untreated through being absent or otherwise escaping caggioation, by new cases of syphilis imported from other areas #1 result of population movements, and particularly by symptomless 6783 in the locubation period at tho time of the original camloation to whick Infections lesions subsequently developed. The seographical dutribution of secondary syphilis in the adminis- Intive units of the district of Lopare, before and after the systematic field campaign, is given in fig. 33 A second control cumination of the entire population is bedog carried out at the time of wating, three years after the start of the campaigo und 22 months after the first control cumina tion, at which time abortive treatment was stren to all contacts in families where fresh anses of syphilis had occurred and 237 / of the cases received ·61 NHTIENT WTH PAN occur. It woold therefore be impossible to control fuccefony a plody by direct db gnostic mans the spread of an infection once it had sppeared a family It le cosequently noonsary that u contacts to the family ar bousehold bo trated with pealdito m order to ensure tidectory spidemiologlalu ducinal results. The wmount of PAM bed for abortive textoont hos naried. At the bepinator of the ampelp the Do Lowo uked u to dlagoted auses. The abortire dow ww dowly reduced to 1,200,000 mots (4 ml) PAM free to u dogle Injection this has dor been adopted for foutloc Doc. No datocos wat obecned when the remits of decat abortire chedules were compered. That dosapa lower than thore uited for curatino purposes are adequato is borne out by the experimental work of Eagle, Magnton & Fleischma od others. While a mall quantity of pealclts is wickut earty to the talection, proprestrety langt dora ere necaurybier since the treponemes multiph between the time of porate and the apparnance of surface tymptom It be dificult in eodem opphols to determine the era uma of aporaro ud mfection. The two al exposure aandot useally be Inked to definite crent a ta sporneto renereol syphilis, uod & smaller quantity of penicillin may therefore be tred lo aborttro tratment than b Docentry to cura the infection, this muling # or prolonging the lovabetica pafod. In order to avoid this danger it is felt that, ander the present cooditions to Borola, the aborthe dow should not be redoved below 1,200,000 watts af PAM The attende for abortive treatment of andere ophtis til from tbox for sporadic repereal syphils. La coduk ryphilia, the first to be considered mun be the children doce they are the most aposed to infcctroa ment, consideration mont be given to the mober and child or ibo burbund and wichther b mdering from tafectious syphilli. Foally the recordant member of the boorhold shopl be considered, uod all members should be treated If tay bero trasports of contagious syphilla. In ono family of tre, for lastence, the haital crumbullou sbored that to children had arty syphilo with papalas In tho mouth and on the reproductit arpas, mod strongly podlttre rerological reaction. The orber members of the family were serotopically and detaily active The efected subers of the family were treated with 4,200,000 bits of PAM to even tjections, while the others recetred abortires treatment Any porcotbal Infection to the family mu this uken care of. When the control erminations Tot arried ou 12 od 20 pombes Water do oltence of repita wa found to the Inn Ad cotirely duercot developmcot took place to another family which Mostried to the 34. Systematic aimination of th's Ixonly revealed that to cidra (Nos I uod 5 bad secondary epailee sith Monty positive Kerological reactions the aber ken we mentorically and athulaatty ·60 EPIDEMIOLOGY AND CONTROL OF ENDEMIC SYTHTLIS ro-treatment. Ia the three administrative units so far anmoed (Cehe, Koral, and Teolat) no new cases of syphilis have been found, while seropontivity has decreased to 28/ of the 11,250 inhabitants examined. If the remaining Feropositive cases in this group, the majority of which received re-treatment for reasons of expediency are separated into agegroups, it is significant that only 43/ were between 0 and 10 years of age, and 10.1 / between 10 and 20 and that this proportion increased progres Avely with age, so that more than 66.5 / of scropositive cases were found In the ago-group over 40. Thus syphilis morbidity as rapidly decreasing In the lower age-groups while it remains moro stationary in the higher although the relative infection-rate in the higher age groups as well is considerably lower than before the campaign started. This augurt well for the future of the long-term control of endemic syphilis in this area. Since the beginning of the campaige, the reservoirs of infection havo decreased in most arcas in much the same proportions as in the district of Lopare. In the district of Gracanica, however the decrease was less daarty marked, as the onginal 1948 survey was incompleto and a large number (973) of early typhilus cases were found. However the results have ulu mately become fairly satisfactory cven in this area. When the area control camination was carried out, it was found that the reservor of infection had decreased by 71.5/ the second control took place 38 months after the initial examination and, as more thorough work had been dodo lo the internal, particularly in the treatment of contacts, the decrease is now of some 97 / It is interesting to note the change during the campaign in the proportion of early syphilis cases to the total number of scropositive cases, representing the decrease to the reservoir of infection. In the district of Gracanica, 42,4 / of Infected cases were carly syphiitk. At the contro) examination 18 months later the percentage was 6.3 and 20 months later 22 At the beginning of the campaign in Lopare, 67/ of the infected population bad fresh cases of arly syphils 14 months later these announted to 17% As the endemic focus becomes smaller the proportion of early syphilis cases to the total number of infected cases also fail. Although the reduction of the reservoir of infection depends on various factors, the prioapai one is the abortive treatment of family contacts with PAM At the beginning of the campaign ach treatment was only occasionally used as its real value was not appreciated. Later when the fire results had been analyzed, it became the key to final success. It is now given to all persons whore chnical and serological indings are negativo but who uro exposed to the risk of infection from other members of the fimily In many areas, it is not possible to toep all those who are infected or aposed to infection under observation at frequent intervals over a long period of time. In addition, doce primary lesions are rare in endemic syphills, the question of treatment in the primary seronegative stage rarely

·NEATKENT WII PAU
bater date. The three infected members of the folly Ad treated, at inter
abs of oo and foor months, two others (Non 4 od 5) vero tra tborttre
treatment, and the reunior child (No 6) acaped treatmeot altogether
At the second control animation, It mus ford that the biccted but
treated periods no choically and serologically peptive, but that thoso
vbo ether bed Dot been treated or bad had bortite treatment had becomo
tafected. The entire humily was then trated, whether toy persons showed
symptoms ar not, and all but one were dinkcally tod acologically peptivo
months later that ons, howbyt bored acological ta provement.
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·62
EPIDEMIOLOGY AND CONTROL OF ENDERIC TYPEILE
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months later on this occasion the two children (Nos. 2 and 3) who had
escaped treatment showed fresh clinical manifestations of secondary syphills
with positive scrological findings They were given regular PAM treat
ment while the others received aborthe doses ance they could bare been
reinfected. Another control camination was mado eight months later
and the catire family was found to be clinically and strologically negativt.
The necessity for plving abortive treatment at the same time us infected
persons in the family are given the regular treatment is made clear in fig. 35
When the initial camisation was carried out, the cotire family was
dinically uod serologiaaly nepatire but infection was introduced ut i

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Al the infected members of the famly reto pren tbe mame quantity of PAM.

·64 EPIDDIOLOGY AND CONTROL OF EXDELIC SYPHILIS It is possible that members of a family may escape the disease despite the appearance of fresh infections in their midst, but practical experience has shown that this u not very likely An evaluation of the epidemiological importance of treating contacts # made by a close study of 96 families with a total of 150 children under 10 years of age, race these are they who are considered to be the most exposed to infection in the family and to whom priority should therefore be given lo receiving abortivo treatment. All were clinically and serologically begative at the lutal camination but belonged to families with casts of early infectious syphilis. They were divided into two groups the first included 72 children, cach of whom was głyen 1,200,000 units of PAM at the Ame time as the infected relatives received regular treatment as a control measure, the second group of 78 children was left untreated. The results, as found in the follow-up camination after ex months, are ubulated below Trend T Clinlastly and retologically podthre Clinically and orologically pepathe 0 72 28 50 21. 172 Toul 72 78 150 This statistically significant difference between the two groups empha sizes the epidemiological necessity for the abortive treatment of family contacts of the chain of infection is to be directively severed. During the initial period of the campaign in Bosnia abortive treat ment was not given but, once its value had been demonstrated in ind?- vidual families, it was systematically applied. Its cumulative epidemiological effect is further emphasized by the results in villages and larger arcu. Relaptes, Refrſections, and Seroredance The distinction between true relapses or scroresistance and reinfection is hardly possible on clinical or laboratory grounds alone it must be mado largely on epidemiological cvidence. It is also evident that, since the environmental conditions in which endemic syphilis prevails make the risk of reinfection comiderable, it is not possible to evaluate the results of penicillin therapy in series of patients by the ammulative statistical pro cedure * used to sporadic syphils unless contacts are treated. It was observed that seological or clinical * relapse was generally found only in those families in which new infectious cases of typhilis appeared, usually before the relapses themsetres. Furthermore, sera restance * sometimes observed after regular PAM treatment of early syphilis, pas rarely encountered in families whicre a new infection had not appeared

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67
form of stological fmprovemcat but, durkthe clinical uod scrologlaul
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The leaportance of treatto all poodble source of infection illustrated
bo 32. The oldest deaghter (No. 3) had boca cated to the arty utcat
care of typhitha vith 3,600,000 volts of PAM. She was still propositive
16 months after treatment, and by then bed developed ctional mealfestation
of mccoodary philies with hypertrophic papulss to the mouth and on the
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·66 EPIDED TOLOGY AND CONTROL OF ENDEMIC SYPHILIS When the first control examination was carried out seven months later the mother had symptoms of secondary syphilis (papules on the tongue and toosils) with a strongly positive STS titre two of the treated children (Nos. ! and 4) were clinically and secologically negative and the serological titre in the third child had improved In the meantime, a fresh infection had appeared m the 7 year-old boy (No 2) who developed contaglow symptoms of secondary syphilis (mucous patchos) before cinical symptoms of secondary syphilis (“ relapse) appeared in the mother Throughout this time the father wu absent and had no contact pith the family The mother and tho ipfected child once again received the samo quantity of PAM but, when the fecond control examination took place, it was found that the tro children (Nos, 1 and 4) who had received treatment and had been serologically and clinically negative at the first control examination had non developed secondary syphilis (clinical relapse) So far as the mother and the 7 year-old boy were concerned, tho serological findings remained unchanged, while in the younger child (No 3) the titro was found to be higher than before. The explanation can only be that as a reservoir of infection still remained in the family-for the contacts had not been treated- . fresh infection had developed. One might be led to believe that adequate penicillin therapy had no effect on warly syphilis and that seroresistance remained over a year after treatment. However when the active sources of infection in the family had been completely suppressed by treatment of all the infected members, and abortive treatment had been given to those exposed to the risk of infection and who might be in the incubation period, very mtisfactory results were observed seven months later and no further coses of “relapse " or "scroresistance resulted. In another case, the initial camination disclosed that two members of the family (Nos, 1 and 7) had Latent syphilis (ig. 37)A year after treatment with 4,200,000 units of PAM, their serologiaal reactions were strongly positive, while the younger brother (No 7) had developed clinical manifestations of secondary syphilis in the form of papules in the oral and anal region. These might be loterpreted to represent serological and clinical relapse. Before this happened, however two children, aged 5 and 6 (Nos. 3 and 4) and, later on, the boy of 15 (No. 5) became infected -all of them with recondary manifestations. No new infections or relapses occurred in this family after regular treatment of u? Infocted members and abortivo treatment of family contacts. When a control examination disclosed « caso of early syphitis 8 to 12 months following treatment with 3 600 000 to 4,200 000 units of PAM OT & case where positive rerological finding remained unchanged, it mus gencrally found that in lnfectious caso had remained lo the family or that # Dew Infection bad been introduced. It was observed that there were very few jastuces in which secondary or early latent syphilis did not respond to PAM therapy within 12 months in a few cases this response took the

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·68 EYDDIOLOGY AND CONTROL OF ENDEVIC SYYHILE FIG #SERORESISTANCE AND CLINICAL RELAPOT" NA FARY WITH A FRESH FOCUS OF SYPHILIS ERO TŁOCAK) A VI 1949 15 m 0 B X 1950 1 어 III. 1952 Non 2009 Secondary aptul O Lord wahitis Conically and molecteally negathre Berological Improvement Berologies oth wachangue or incred Trot 2.000.000 mile of PAIN tonsils. Infection had appeared some months earlier in the father and mother (Nos. 1 and 2), both of whon became strongly positive after havog been serologially and clinically negative at the first MIDAuOn The other children (Nos 4 5 and 6) were also found to have remained scrologically positive, no change apparently having occurred 16 months after treatment with PAM The entire famly was re treated with the same amount of PAM, and 17 months later they were, with one aception, all clinically cod serologically negative. It was found that relapse or repfection did not occur in families all of whose members had been treated so long as a fresh infection was not ·TLLATIDIT WIR PAN 71 the real word equally good in fumia where the fer forections are add to hahhy partout pere treated u the same tims Rok, György & Ingrabam Schambery & Steiner und other hand drraced the you that, in poradile rectal mpbills, true relapse are less [requeat lo children, and that ince they are la exposed to renfection thato adatts, better retults are obtuled from penkele therapy la children. Horetor docenteno syphilis, Infection la most frequeut in childhood, the Addo polght be opected of reta faction. The Indeed, nu food to bo the aur a compartion of the ap-poups of persoas poltering from re bpsa va completing PAM treatment about that approulmately 50 % of the cases ro to children mda 10 an of er The didcresco lo the Garbadoo amor proups of relepas in edenis and sporadio reaccal typbills soost be attributed to the different modes of trombaion Vecreat far the muainment d uulmatury a sporidio sypbills, and doorvecercal Is childhood to entenio rypbitis It may bo armed that the response of the human body to peolemin treatment might dider with the up of tbo tafected perso0 and that, la spite of the amo treatment, relapres could oocar more frequeatly ia samo -poups than to other. However on compartag the effect of Wheatical treatments on the merological titres of persons of diferents, but to whom the darution of the doceso was approchostely tho me, do dgabianat disertace mus found (41) ·70 EPIDEMIOLOGY AND CONTROL OF ENDEVIC SYPILIS introduced from outside. To truce the spread of infection from one family to another was often very complicated but fig. 39 does Indicato the courto of " plng-ponginfection in to Beighbouriog families. Whea abortivo treatment was given, tho infectioumets was cloninated in both. The influence of residual fod of unfection may be seen from three Audios mada. La the fint, of the 240 inhabitants in two village in the district of Srebrenica, S1 were found to be infected, 40/ of those having early Infoc tious syphill. Both cafected persons and family contacts were treated, and at the control examination eight months later not a single family was found with either a new Infection or clinical or serological relapse" This is in contrast with the findings in the dianet of Gračanka, where less systematic work was carried out at the beginning of the campaign. In August 1948, a serological examination of 84 / of the population in an administrative unit with 3 623 inhabitants was carried out 27/ were found to be seropositive, and 135 cases of carly infectious typhills were diagnosed. All infected persons were given a total dose of 4,200,000 mits of PAM but no family contacts were treated The follow up examination took place 22 months later and 53 new cases of secondary syphilis and 7 clinical and 8 serological “relapses" pere found. Of the infected cases, 46/ were ro-treated and abortive treatment was given to the children of families with fresh cases of syphilis. Tho percentage of the population which was seroportivo remained much the same at 224 A second control examination took place 18 months later und 11 OCW cases of secondary syphuis were found in ono mall hamlet, in addition to 1 serological and 3 clinical "relapses" The percentage of seroposit/vity was now found to have fallen to 58%- A similar situation was also found m a village with 573 inhabitants, 128 of whom bad syphilus, 22.6/ with forectiow secondary lesions (see fig. 40) Dung the initial examination, not all the infectious cases were treated nor was abortive treatmeat given to contacts. At the fire control examination 20 months later there was still a large reservoir of infection in the village 23 OCTY causes of secondary syphilis and 4 clinical relapsen were found. A second control camination four months after the first showed that the new cases of secondary syphila had been reduced to 3 whllo one "selapse* had occurred At tho thund control examination 14 months afterwards, or 39 months after the initial survey no DCW Caso of syphilis or instance of relapso * was found. On the basis of the observations illustrated above and the findings in other areas, we condade that the great majority of cases of apparent relapse or troresistance in carly syphilis are actually reinfections. Reduction and cumination of the ratervoir produce i corresponding reduction in the number of relapses * The most successful results Rere obtained in families all of whose members were infected cod to whom treatment was given smultaneously us the family reservoir mus thus climinated at once. Bat ·TADIOIT PITA PAR 11 nc the resolts were equally pod to females when the few tafectious est and the healthy poyon mo frated at the sure time, Rok, György & InphamSetumbery & Siaper and othen hatt atraced the view there in tporedio Teocreal typhiits, the relapses are less frequent to children, and that once they are los aposed to reinfaction tas adaltz, better resultat obuiadd from peokeilla therapy in children HOTE Hoce, la endemkryphiles, infection is most frequcot to colldhood, the umbo lahat bo aspected of relorection. This, Indeed, nu found to be the cause i comparbon of the roops of parzons Alertog from Lapes are completing PAM treatment shum that approximately 507 dlho aso ko la böldren oder 10 ran of art. The difference by the distribution imaoof 18 proups of relapses in codemk uod spordic recreal syphilik sonst be attributed to the differcut modes of trantud on veacreal after the ablement of sexual maturity to pondic syphbk, and Doo-Tederal in chikbood In eodetnie syphilia. It may be arried that the response of the borain body to penicTHA treatcocut migha dute with the use of the Infocted person and thus, in spits of the Mume trupem, repeat could our more frequently lo 2000 age-groape then to others. However ou comporlog the effect of Westkul treatments on the serological site of persoon of diferents, but ta bora Ibo turuan at the disease mus approacimately the mos, no egiticant dierence va foord g. 411 ·70 EPIDEMIOLOGY AND CONTROL OF ENDEDC SYPHILIS introduced from outside. To trace the spread of infection from one family to another was often very complicated, but fig. 39 does indicate the course of plog-pong" infection in tro naghbourtag families. When abortivo treatment was given, the infectiousness was diminated in both. The influence of residual foc of Infection may be seen from three studies mado. In the first, of the 240 inhabitants in two village in the district of Srebrenica, 51 were found to be mfected, 40/ of those hapłog carly infec tious syphius. Both afected persons and family contacts were treated, and at the control examination aght months later not a single family was found with elther a new infection or diolaal or serological relapso" This is la contrast with the findings in the district of Gračanica, where less systematic work was camned out at the beginnlag of the campaign. la August 1948 a krological camination of 84 / of the population in an administrative unit with 3 623 inhabitants was carried out 27/ were found to be seropositive, and 135 cases of early infectious syphills were diagnosed. All infected persons were given a total dose of 4,200 000 units of PAM, but no family contacts were treated. The follow-up cuminations took place 22 months later and 530cw cases of secondary syphilis and 7 dinical and 8 serological relapses were found of the infected cases 46/ wero re-treated, and abortive treatment was given to the children of familles with fresh cases of syphilis. The percentage of the population which was seropositive remained much the same at 224 A second control cxamination took place 18 months later and 11 2017 cases of secondary syphilis were found in ono small hamlet, in addition to I scrological and 3 clinical "relapses" The percentage of seropostivity was not found to have fallen to S8 A similar situation was also found in a village with 573 inhabitants, 128 of whom had syphills, 226/ with infectious secondary lesions (sec fig. 40) During the initial examination not all the Infectious auses were treated nor was abortive treatment given to contacts. At the first control examination 20 months later there was still a large reservofr of inrecuon in the village 23 new cuses of secondary syphilis und 4 clinical relapses Tere found. A second control aumination four months after the first showed that the new cases of secondary syphilis had been reduced to 3 whlle ono "relapse" had occurred At the third control cumination 14 months afterwards, or 39 months after the initial survey oo ACW Caso of syphilis or instance of relapse * was found. On the basis of the observations illustrated above and the findings 10 other areas, we condude that the great majonty of cases of apparent relapso or croresistance in early syphilis are actually reinfections Reduction and clipnation of the reservoir produce e corresponding reduction in the number of relapses The most successful results acte obtained in families all of whose members were infected and to whom treatment mus diven simultancously as the family reservoir mus thus eliminated at once. But ·73 KDO O T INTECTION ma DEATTYT CURACAL AND HOODICAL KIDATO ACCORDINO TO A XT CANO O ACONDARY DIDT 0 SYPHUS AND PHONTHS AFTE TILATOT WITH INN MOT OF PAN 3 10 D 0 . ماد 41 only 70% of the popolation wu ermined. The treatment wou 3,600 000 its of PAM dx isjections Contacts, borerer mere left untreated mod un appreciablo rekerror of Infection there are reained. When the Artt follow-up comination was carried out nearly two years later the Altaatioo u more or less Euchan pod but the team mu moro careful The me done of pealaltia mu stren, and, to many fadinca, family contacts were also treated. A second follow-op cumination four months Allor the first bowed that the bafectious cha bad decreted to four On this occasion abattro trattment n piren to al family contact At the third follow-up armloution, which took place 9 megtha ater the trut curvey DO OCW Cum nu found in the village Infectionne had been diminated The best Rod quicted results were obtained when the entire population could be camiood daring the tattel curvey and when all tafection auses and family contacts were treated. The achievement in the villape of Brusola may be uten u en cumple. The entire village of 350 inhabitanti Tus merologlaly od cinta y cumined. The infectiod-tuto wu found to be 6666 sty Infectious syphilitis koponating for 48.5% of the aua Tbo loll comtaatioa mu anted out in April 1949 when it or en Injections of 600,000 units of PAM each were pres to 1 infected persons ta idditos, abattre treatment mes pires to u penons to familjes with axa of acy orpher. The source of infection was therefore under control ·CHAPTER : REDUCING THE RESERVOIR OF INFECTION Owing to technical difficulties and to the shortage of personnel, follow-up caminations could not always be carried out to the Botlan campaign at the intervals considered most appropriate. On the other hand, this very sate of affain offered an opportunity for a doter epide mlological cvaluation of the results from period to period. In areas with actively expanding foa and numerous fresh Infections, the follow up examination should be arried out at a farly short interval after the initial cxamination, possibly three to four months afterwards FO. 4. MISULTI AT FOLLOW-UP DUALOHATIONS IN AN ACTIVT FOCUS OF EXDEVIC SYPHILIE (TRNOVCO 20 Nam ficandy Shell like 1 0 X7 1931 Yu1943 V 18.30 IX 1980 Central verte (enth you) Number of Whabitata 50 Inecontex If tho interval is too long, the realdual cases resulting from periods formerly in the locubation period, or newly imported cases, may under certain conditions, diminish the inal effect of the campaign. It is essential that the loterval between follow up caminations should not be longer than one year La tho amall village of Troove (fig. 40) there was an active foctus with a relatively high proportion of early lofectious levons (29 cases) together with 88 latent and 11 tertiary cases. The ridal cumination was incompletely carried out owing to the limited experience of the team at the time - 72 - ·75 KIDUTOO THILEDLID OF LTICTRIX Eptteplolople lookkants of this blod will alway occur and shor dauty that further popevtdan s terory after organized field compelos lo bal mau baru come to end It bloteresting to consider the general results achieved botnfected wa up to the those when it contato coquiru i specially organized feld ampaign. The pridoi decline to the scropodittity and to the number al arty Infectious car to the administratte mit of Sapaa, from the mart of the campaign to the last control plastica 27 mpoatha later ka shova in by 43. The first follow-up obattoo took pleco di mooth fter the latda mrrey during which the 136 Infectious cases found had been treated wah 4,200,000 units of PAM eich During this period the scropositivity te hed decreed by Darty ball, and the reserroir of infectios, by 073/ atmeat with tho am dotis rus repeated la 24.2% of the loldal che Tuo Xcood control aamination ws nada 21 Donths after the Enklal survey and it was discovered that propositivity bed decreared to 57% Alghero which tachadas both doubtful and posttiro reaction The reservoir of Inlection, bortver was only slightly reduced us abortire treatment bad pot beca gres La the village of ledledja, an old enderlo focus, a abrly high percentage of treated anses remafood seropositiro Fren klar re-creatment. The majority of these were bato bateat custod were sted for the wind Um with a birger dose of PALI, 7.200,000 units belos even to three Lafections. Fresh cuma of syphilis vero gimca (be Do teamet ult previou contrattoa, od abortive treatment (1,200,000 wds) no pored to aspored nicoobers of faroles with fresh syphit. At the third onto atlon, 27 months are tho ampaign bad started, I was found that the seropostivity bed falica to 14% od that the retervolt of Infectioa had been contacted Improntcot of Intes conditions uod peneral hypead will leasen the rok of pronting codem rypbills who came rappeur Although social aod cconomic betterncot pros and code ny it is Hikely that penen! buprave.com Botola will be time to the polat has not been ratched where the relacrodach, od Suther Dop-Terctel rawnlaxton, of infecdoo withbo od among famshes ao be completely atmimies. But tho mbat that this I resolt la widespread infection of the population is pretty reduced by the sphasemlolopical ont of the Dep-treatment citempel The reservoir u boleh beca broaght onder control, and the attitudo of the people to the problem bas bort attared this doe partly to LOTDO stonnal lisprovocat in social and cooowl cochlors, partly to the work of the held is usd to the pool proper of the alapelys, and parthy 10 the fact that DAR ar of eademik syphilies are now detected mom reply red ca be more quickly dealt with ·74 FIDE FOLOGY AND CONTROL OF ENDEAC STATES Since then, five follow up examinations have been carried out. At the fourth, held at the beginning of 1951 only one young man, who had previously been abseat from the vilage, was found to have a frab caso of syphilis be was treated. At the last cramioation (Apri 1951), three yours after the Hart of the campaign, the village pou free from infection, There were no new cuses of ryphilis, and only four inhabitants remained seropositive of those two had doubtful reactions and two positive, one of whom was a woman of 63 whose serological finding remuned Hrongly positive despite three courses of treatment with PAM she had no clinical manifestations. However such success could not always be counted on. Singic instances of fresh infection were sometimes encountered after the second control camination, but they were usually found to be confined within Limited areas and to roar in a small number of families. Such relatroduction of the disease by a member of a family who had been absent during the campaign and had been neither examined nor treated is llustrated in 0g. 42. 710.a INFECTION OF FAKTLY FY RETURN OF ARBENT KOLLIDIR OUNO NOLISICT A VI 1948 odbye og nelly woulu osa como O B Y 1950 & $ C XII. 1951 fa bo a Secondary typit aina ya watograat worth O Not surined Mtumed to ·75 IDOTTU TIL Lvon OF DITETOR Epidemiologieel beldests of the Hind will almayı occur and above carty that other Alpervision is necessary to organized Idd campaigos b. locul ou have come to an end. It is later that to consider the benzl results Achtered bu pfected a dp to the time beati ces to require a specially organized feld chopulm. The padual decline in the seropositity and in the number o arty bafcctions cose in the admlolstretto unit of Sappa, from the part of the aumprim to the last control caminatha 17 months later is howu ta eç 43. The tre follow-up coumtoatlon took place du months after the laidal errey during which the 136 Infoctors tases ford had been treated who 4,200,000 units of PAM arch. During this pedod tho stopositivity rete bad decraused by party hall, to the reservoir of Infection, by 1734 Treatment with the name doar mu repeated in 24.2% of the batth coch Tbo necond control cumanton m mado 21 months after the tahtial prvey tod it wus discontred that Keropositivity had decreased to 57% 1 figure which focados both doubtful od podtive reaction The reservoir of toroction, bovever wu only nightly reduced us abortir traumat had box been stres. In the lace of Medyedia, as old andando forres, + farty high percentavo of treated and remained teroporttivo eren der re-trentuent. The majority of these wat late batent cus and PETE treated for the third time with a larger dose of PAM, 7,200,000 units babot prea in threr Infectious. Fresh cases of typhilis vero give the same treatcot us at pretiom cumination, and abortive treatment (1,200,000 mit) nus piren to all exposed member of families with fresh syphilis As the third control animation, 77 months wa tho ampio bad Marted, I ww fotod that the ketopostivity bad fallen to 14 / kod that the nervor of Infection bad beca dicipated Improvement of Ilog conditions dod penal hypicoe will loven tho rik of preading codeak yolulis ber as rappeur Aubooth mocul ood economic bettermecat pians are ouder my it ba dy that a reneral buprorecent in Bostola w take the cod the potat bas not been reached bent the destro doction, and write DOD-Yeocreal trutinidon, of totecthon within nod Among families aan be complexey diganted. Rut the Hask that this userult to widespread infection of the population is pretty redaced by the phomolopical effort of the most treatment campaign. The rexertor u bole bus beco brought oder control, od the uritudo of the people to the problem has been dered this is due partly to PO DO fan loputtent in social and economic cooditions, partly to the work of the Bold teams und to the real progress of the campaign, and panty to the fact that may ao dendevalo typhilis od Dot detected moto rapidly and was bo mort quietly deal with

·76
ERDE DOLOJY AND CONTROL ON ENDEIC SYPAL
MO. A BROMO ATIVITY RATI AND NUMBER OF CASE OF ACONDARY
SYPHILIS (HNO SAPMA)
orta note on the und TretmaXJN
Lernpelanti NX
First Control Ednateur
Beroper 127X
Kortera
IU
O Mossber of
credery op

·REDUCING THL anyon 0 DICTION
m. a. FOTO TTTVITY HATI AD AND OF CASO Of c010 ATY
TYPHH OO LAMW) (conto
And Cru Loldet
with UX
combined
un
415
word
Terup I LAX
thama
lud
wipo
we
12
21
cun

·78 EDENOLOGY AND CONTROL OF ENDELEC STEIN In our experience it is possible noder favourable conditions, uod in limited areas, to cradicate the infections reservoir completely within a short period of time by mau treatment. In other cases, the disease can be checked and the infectious reservoir reduced to a minimum over & some what longer period and ultimately eliminated. In both fastances true relapres and reinfections, and reintroduction of the disease from other eruus, must be watched for The epidemiological dtuation cannot conceiv ably return to its original form after one or two follow up examinations have been made, but constant fupervision of previously endemic areas is necessary as part of the long-term programme. In Bosnia, such super vision and health control are provided by one or more health workers remainlng in the field between control cumications and after the field campaign proper has come to an end. Being selected from the field teams, they are familar with endemi sypbills as a rural health problem in all its aspecte. This system has already proved invaluable in achieving lasting results. The health workers co-operate with the local health centres, wluch asume the responsibility for keeping the discus under control through their normal machinery against communicable diseases, in the consoli dation phase "w of the long-term programme The present programmo is serving as a bridgehead to the developoncat of general public health services and to the expansion of the machinery against communicable diseases as advantage is taken of the advances already mado the population has been made aware of the need for such services, and its aumbers are known saff has been recrunted the basis of a sound record syutem has been established and, in many communities, facilities have already been set up or cutting ones apanded.

·SUMMARY RÉSUME Fada ceo badatta tutta L'histoin you clone you la syphus Wty that will botroraced bato to relemblablemet importa a Book ble from Here countla mancat donda por divoros poqma et padeda oltin, to the Ottoma omla qoo wat les imta ottomme qd cot plays the sto raketa td D egtes will la propuer Care the end of the 19th century throty matult du trepando Book wap to Do ad Horgorb Factori rok in do XIX Ecle. ood food for 1905-11 hort, Dupre la patistiques des moto 1903 wyboans arrod od in 37 datrict, 1911 41.398 cm dlaga and decide 44. do fundcou da moltes mendan dems 37 db bacter of 3% Radeo made from trict, soit n tume d'Infoction de Ux 1926 to 19, a rida trmo soloplaal lo worections pratiques de 1926 & anlations not out, med 1933 got 57.965 tr, tot with 1963, a ako0o-nos of 1117 d mlectloo do 113% pour la population ad population and cambo. po 14th Yopoule health cm L'wolltration youpodoro e trupit dom ho dorcloped • mulanside depola 19A o tuo compu ml mypham-control propon, with special syphilitique dans l'ensemble de porc dort to control the co-Torocodilo aforçant tout particolarment de com po Dom The World Houlth battro cyphilis eode d'adou noc Orption de United Nations obtenon al titt on Botolo. AL doul C. Beren't Pracy Fond dando du Gounomoot you, en participated at the rigat a b rontation Mondiale do b Soad at lo Y Contract For Ecoboral Fantas Luteronoml des Nations Vala o al porrious control dort bed pour le seconi 1 Ending out participar bor TOCCO princrpally bear no i dort. Toutes les compea ott home currtoa aterat popo for the deserta loca por don bed bear them and boc coro dhe rule, cutout para que roa bad boro bald on the detal bod db 'wet po dando ry prolol nther tim a to opt matigarea obie de la popolation boboboplod poct of the me * go on tult attach i lpectu dil pigo . pathologique de la mund plutot qol so uporablogi Dhoming the concept of endanto En la notion de typoll code phula, che uthor strat following in indar darti comme dans didendabta of the dom: du contes de cette melde () Luty dot roty tror 1. Es bal, allo na po tri drol coacdn norra por vores plates o per conclou det to the cod populdos, o per la population de courte montre scoated to childhood. paladus too. La plupart de I cotton twotuncle to do tance It's pret la mu low 2 Eta itpender ding does noong Rodod o dochon rod poor cooooo o lana daruction bulo ·80 ETDELITOLOGY AND CONTROL OF ENDDIC SYPILLIS and social codition, with primitive cooditions économique et portales delano manitary and dwelling innents, wo rables, a dont la popolation vit dans des pan lopeinenti prtmidl pourvus d'installations maltaíros rodimentalra. 3) ID particular modo o spread 3 En raison de sa modo particulier do through contop dauncatia and bourbold propagation par 11otermediair doblets utensils, and other direct and Indirect do certiques unel ad ustensiles de contact, after results in the partico ménars, ou par d'utres contacts directs of Infectious lalong in the oral oplon u ou indirecta, lo prende symptomo consiste tho Aret sypto fréquietament en des Krions infectieuses do la riston bucak (1) Thero art go cssential differences 4 11 anisto pas de direccs Impor between tho dinical picture of codendo tanta entro to tableau dindqua da La typidlot and that of sportdic veneal wypalia mdanique et celui de la sypillis syphill porsdique d origlos vociende Sypanib la Bomnis caust be seen as an En Bosnis, Lyphilis doft etre cordeste cpldembological nither than a clinical Como posant un probleme epidemioloprobleme. It becamo codeindc bocus of quo plutôt que dioque. Elle est devenue the exhtenco aver centuries of epiderdo endora que por solto do I alsona con loglal features frourios a distinct doo Liro do fastemy spidemiologiqua do venereal mode of praed. It is malaly naturo favoriser un modo particular de food among the mind population, but trummbedan noo ventric.co cto est It la morely distedbutod oft diartat rtpandne principalement dans la popola areas, or even within a art, despite tion rural, malo p est pas répartio palepurenty Lantical living condition. This ment dans la directa zona, a bien que UDOVED distribution may be egplainod by frequenco peut, malgré l'identité apps a variety of facton, including social mod Tento dos coodi thout do when yrtar 1- Aumlly atstoot, population comments, Herr d'un tetelo et rem regiac Cette topography and poor communkation repartidon Intrudere do la maladie peut Impoc podhreres e, notamment par la babitades familiales et sociales, les Agrations loterieur, la topographie et Imatanco dat role de communication Tboto is trompto ondance that done family linda apd wohl contacto constituto n tupactant factor in facilitating the sprud of codemic syptures. A study of prevaleta la relation to the size of the commtudy abows that the maller and moto compact tho community the bigher tbc plocttoo-ts,u thero 10 more opportunities for trinition of Thopo Mana padom. It is also found that, water thero mu. Wat proportion of borected children, wypalii we moro scthye und the codente pres dog bile, wbero that proportion is low the disease mu les active ud tho eadem muntag At tho ame thing, It mu observed that tho Infaction-rito umont children werd considerably according to the moba of perbots tofactod ud opo study of 642 Il y a de noobredies raisons d arrettro quo la prornicuits du to food at 1 froitone dy relations locala congit toeot miectar importuot dans la propa pation de la typhill endriqoc. Uno dodo concernant indicado que lloportteco Kumérique d'une collectivité peut arreer Rur lo tant de fréquence de la maladie a peronis d dablir que tant est & tutant phus cert que la collectivité et pole Dombrosa et Ao plus remette, co 40. macroit la risques do trattsloo do Treponema par I . et constat, d mutro parte que la typhilba cu plos thro at d po codendded crotanto dens Itploos od tro puedo proportion de colantt kont lafet's haventat de att motes throat ron codentale led i ocrott odla proportioa ·DOWY 81 tricted to shared that b2% of data bloco a poco. Ilu tom do detran dan mbad obe, d'or per, to do tion des mat male comicbtemat doo bo robe de pereti contra Irunt todo por no 2 bilio better que de 20/ d'un dlo, tanto la om blot tieto Podenke typhlebo dogte to Do a longtemps a typh the be beolo di perly becomigo endlos como mudo beton of the ethod to the of the parli Byte aviopique porta per l'atthode ha prohhe code. The purptomuto de mada tot dan omilla pot u of both odcok mpbula ad por dhe nr. La vymptomuolosto de behartha YRRI matildab tolmd tot odbrdoe de durerea pero de cale de la to de drop to typhis pandite dorintos álom, na be boch detta tou dibena ale traitement par les rondes poétique bmw to reml court of the blico do pobo co do hound in the autode of the patient tntpoodne. La carta da ptatot Son model peb cards books dans les troision matonta do dog drendy and death or Tratado dos talde Coriolampbells product loputty for work, mikopo de blocher pot conectored by to population mely chroedgao god et quo mocok mortelle od to be aby bumubo se o torceptioodiesem my dar mon doucloped coodtool buth tool, la buban podno- Homic bo teploos en de bu bem fakt po kc de tal que les Tradual besproket b the condition tott rom yeu de population plm eroof the roul population, maidoos of habet. Toutefois, de la regione rand put on w cookland Maboda od los contidos de vio tout program and obenda to mock und social Verkt odhala, ker metfontos de noncool Typhit opt cookbo sctodlamat to lourds chute de par Prayer lo dit doppemont .cocomique My belon moldak La Watoa pestoot Tudung La podol, my contations of er sphin endiger Irwort de poup bowl than to occur la la obratique de poupas boporto de 1/ of the cotaba. Toate acor popolitica ako quod ultroon roka dead bandy on the condido 1X des le bufectloos oota. Leor poder lich too boldog nu cortand Apparthen decod wrtout des conditions ad on the bed the look Lod to learn infection contract Dome ante, com nel que dolgo do Bore bocopocraty boorrctty bed a H. Dans la popoldoo bowegun, las wu kombo occobond thebino poolt koot ont trucola of brp moba doda bor bonte, per rok doo talde nombre pd y rautta pery loans de creto Rote, touches oth plant plus force, te ber peberry line poraba a provoquen og du of the prodher's ship to found The Welco patrem. Co con il ugg aus contact breat for beds the root of pet Danuben of gro, per comple, la dona primera do metoda obert perlota cha W tootroo the cat coal lalo pho conta direct pooloo ditt perubatan ibodat l'atta de lagde matemd do pod por detrtpoot provenant des Who do ga dobit pon bocna de l'entrot.

·82 PIDEMIOLOGY AND CONTROL OF ENDDIC SYPHIN Lato punifestations to stratilar to thote Los molestations turdhra root compt of sporadic vergul syphilia, with rom nbles i cela do le syphila spondique matou lelona on the skin, to the nero d arigtoe bodemde, mec Hlous fourpharyngeal roplon, rod to the orico Des de la peau, de la réploo Hibaoarticular system. Contrary to previous pharynglenne a do srce outdo-articobellal, Beld investigation havo obown that biro. La ricerches oot permis duabur Lavotremont of the coutral Demos Shem ques, contriranent i co qoo l an croyait o occurl patctdemment, lo systémo nemu central ponit eure loncat atteint. Superinfcction of an already infected La Aurinfection de Rufets de infectia at and lernte bort ha considered to be the allergique et considerato come la pelo chle reason for the frequency of tatary cipale cura de la fréquence des Aston lalool. Wbro living conditious Improve terthiran Lorsque, paralement à l'amt and the chmoes for popoarta! Ant fontos de conditions de vie, lo staque miocon decret, or stien Infectious au de trutdoo noo-rodrieme docent, ure treated, the member of stimo tertiary et que les malades contagieux root trait, london databa la codard aral The les lesions tertiairas achos destanant plat ther frequency reprezenti e spidemiolo rares dans la xoa d codtunkciu leur til plaal lader of the state of activity of rural de fréquenco peut donc etro and reprocuendere foc ter l'indice Spodnalogique do lucttvind des foyeo endorsques o millou rural It w previounh thought that the non L'abenco do brloos congenitala falt occurrence of congenital manifestations tupertrent consider to contro l'ono da wus one of the characteristia of endemic ancttristiques de la syphik endedoc. myphIHR However though ners, they do Male, tout en tant rares, las llons de co OCOUT Tber nurity to lorpely due to the genro surviennent parfois. Le roi ett fact that, tokotloumas bo syphill doc, poor beaucoup, av lalt go f'beste docreates with time and daca in cademic tlosit de la typhla kraft avoc bo tempo syphilis many yan penerally dapso be et comme, dans la typhilis eodemque, do tween tho acqoldtion of the Infection and nombre des années coulent robralo to attainment of maturity thero Naulo ment entre 1 époque de l'Infaction alipo probability of a mother's dying birth to de la maturité rodile, ypou do chance comptotally uphillthe child pour qu me femra donno palmance im cofrat bértdo-poititique. Ono section of this paper deals with the L'auteur delt, dans une des sections orpanation of the field compelp, erp do rapport, Japadation de la amamo phadzing that can finding was done by Antisyphilitique et pouligno quien plus de systemate serologia areening of tho contea dinlqons, an icon, pour catro popolation to addition to dinal to deportes des malade, na rosactions favertipation, and that follow-op cinta trématiquement étendues al ensemble de too focluded rooquining not only la population los comendo coatrol oot, trattod and but the roster of the d autre part, portt nou meet or los konceputhte population as well IA al mlada tutti, mbi encore mur lo resto ypproximately 95% of the total cos de la population meuble d etre coatepopulutloo lo codemkere u armined mode. Dans l'emble, poba do 95% de tod 33,238 wa, or&1/of the criminod la population recensto ont é comoda poprimion, we treated dans la zona d'codradits a 19.23 mlade, sołt 81des permand enim ades, oot té rueerds traitement. As the highest pfection to w found Lo tut d'Infection le plus dlord trot to Dorth-caster Botte, the most intended Ht observe dangle pondant de la Bonde fold-rock mu done to that tran od cat dum cetto region que la campagne ·2 pCARY platy pre to da redondo I mooba troc plus de la Mche proportion of artyke, to poate dorade ter tale of 1'co order to control de pod of bebadian the cool Lopte forte proportio do tros sctha fod ba de tot po. Walang po, on d'entre ed plement que porta la propagation de beba i parths des foyer dette The wool procala poolel. Good L'emplido pollino G prochado das wa 2 km Door (TAM) The 2X de Donostante dumt. prome dotate to the room The stam (TAW) a cobbod . et trument for student dolato poco do campo. La 3D tmcp đang chce de trachemcot porn tube cool detly or every woond dry ba toal of taht e deron talanto har na botocolan, bolo at doble de 3.000.000 4.200.000 de an, however the tool do thea de TAL, partiap tafections la ng bacon. In fond the qhouding od pretique sous la dictum tort motoren who the water for Dans cette en strat de on, toute dorp w tra loro botection a b fols, bado totale doen omheden cord, cong cody the scheduledopted en ole thjection. AOCID no prodod on the topomniphlaul out i oborria den lortutat, que la the dotat cu mod on to be do pobudo ut deterbo D. of a fund Expertotodabo loan pucun balactoo lo colx made a dog's bloction of 1,300,000 in do trultempat donc ad bor Ford PAM, and the mouth or to doool na ptun od non prando Luca boa bwo wty baterior to thow obtrtoed Cacts du dra oo at no potuto wol totoo.... a balade co y mantas atpat. Do calcoot noon, a thry aptit wao njectio oko do 1.300.000 utalon tult obund ud de destes nos crudom do pos Dutra At thy of apoph by Au début do opon og pormalt thought that the child of perplette que demo do persona do ba tudo done y la tratto. Glen bit cettato da ularo parole cha k bocent cret tha # by the ha titudin, terdapat po roon pohod wo wompad motion, compte qort promenit puti da prona la choo na from other area Wetta ca utrydent Alemi din pero cubettg tho det do DOU A Dos adatore d'utra bed counction the tout troosades per a periode duc truy cort Robe de o comer budoom momcet du buren. L'atoar or thoda data to al control Quo qilmpore ter op Guntattoo, tabacootered to dulanti della tolaadudla portat la boldurant to loos Docta torta de cores dupoodi toone, atlard dolnoot tre, i 300 rrie, pratiqade. the capotba pead se niyotol power tots Antaaridotto che tonia coorbe pe propria old The te od pola nudit were be she the cod pop thdoo cool moldes out to obtodes les repom Lo staan meiro apm bad dret ons od a dolod od tently population in a od toonid roma pon code cortos voy tuled Hottie, to barn bdia vem Lecte a la calent toke Copot, da bodo ·PODOLOGY AND CONTROL OF ENDER ITTIS Literare it to Is mit 4 çant lmplak, The asalaaahhhhయం mdos Los bath peo dae Waco, nec s po pierry repay, the orico mecans des de la moda dia Corny L PERIS planten edo o CD bez brisdreas brez cu la modablir Dar correto the class ore, Cateria de les 1110 OC Ik pa poutal rosatt et pieci LIVE Sarance of nara chand La mfano es da nosa Autorok host common to be the ther poes on coolete commen chord roca for the frequenyttery at om de la renda kan ledona Hohtos contos DTC des Losyes porno od the comes fx denne tit Koration danindarkhra miel decres, a ben todos os dhe tregon se modern, at totod, the trade he testety markralia campara anth, Lettons dirbantes in the man T.03 le bus tortisho ha detenera pilot ther frequency Icon question to dog losna diam id, look moalade of the started thity of mal de frecare din tre che detoc foc ter rir hundar de dat get pa moral Its prioodly thought that the non Leo de Las copiala cat CLUTCDE a concilia Apart Otte er en de *** aoc a the concepts of code anastiques de la pols attest syphile. Hontrer tous, they do Mod, too a domi ranet, la act OCT. Ther ty largely due to the FINT A partadt Leo natt og fact al bufocdoma in typ bata dos, por los con las poc Into courts wide that rod stoc tu tents tot de la durat tree text syphis your family dapat be a comune, dins la batis odio. ad tates the acqalotion of the Infocom od pocabres moto would storal de uticat of the conto tere & Sitike men enor rango de Contados art probablity of a mothers stitne burth to de la mature stoc, yaren & St congenitaly wyplatit c.21 pour que me lemne drat necoce a on colpot berkoop buite. Oot spodop af ibb paper deals with the L'wtror docrit, dans une da otvo arponization of the Red Carpis, dramon rorpiotason de la phashtag that connodiny v dome boy tintulitique a roolippe quo pto dos patentc crologlal tening of the um moquet, ce pot cutie popolation to addition to dipical kohustada vlade, mordaci grelndog, od thar forke-up conto numquemco testoos alcanSkedes coas actocad mat Dok only b popoledica ksammes de condole tretto con but the contact of the d'autre part, rond de decet fut les potpuidlo popolatos al IA AL mlades traites, the cont par le rest prodmetely 95 of the tout ce do popoludicotoubks d'eut courts popuhdon ta denda caixa med, unde. Den l'obis, sudaro od 35,233 , OXI the cod I popalvio record oot cd cum population, mert treated. dans les mona dedbomsint et 15 malda, tott do rato con stes cortos o maitement the highest bafect.com w food Le te infection le plus de tot ha porth-easter Book, the past tutooth Habarit dans le port en de b Budd, odt at done to thet og co dans cette replica que hayupo ·DARY prtortly dra to wala na to make me bo plus d Tote u se Want propordod daty dom, b place to dopadim duke o l'op order to control the pool a beton Irak mate la plus forte proportion de from the bod tada para poco wung Hente, otto d'oder Band nipidement que poseblo le propeptico do mutta partir da foran dhe The polyroobos pook G to od Logadoptati proces wło 2x de code (PAM) Ibalo trec 2% do portiera d'alcol. prored doctor other competes The tu (PAW I can tribol de trattino betale for um prently dictwo in occa del ampuma. L 1,000,000 to 200,000 na PAKI cont de traitent pour une combo Aby or may noond day to toul al tatt med try tudodatnathan bor mic doosh In one of dotato de 2.600 42000 watt bon de total doo v dres do PAN perde to pe balactions de bouction. We found that qpotif. o pratiques to a low disco thert va ord bether the tool Joan Des centras wila do tohy loun srca la coe beliction a la fok, dom totalento donde todo own coon goody dancehala wdopted on mudo Infection. And also paded on the toportblad ducatum na do obronnte dans la ruttaa, qol ha the naturens bod on the roba dow poble alt kat dobre of our foond. Expertmpts were ablo Rode o podpory boductions he dots bodo ob toglo bledo o 1.300.000 do chloe do tretineret u door di bor o PAM, od de renda to be buvo doond tot plus ou moins prada bi boonta mo y buferior to thon tuod dacobs do diren no trabre tuh to dota. do mundo que ele ei ddodih. Oo e planet committere che 1, i to bajection modo da 1.300.000 whiclottattats obrera Jogado kaldest on then chox des dos plus Al the part of the ampela, no Aa ditor de la copepo pot thood at the cold a perpetuudeg Pour le haut de pabana de la maladie de byla tratto bora bat rukalt tout de choc pouble de # book chat dat hy nicht la trecotot, per a toda parede ochod pro Who neupol letion, compte qo'l proronit porto di person you lordo troca obe tro okoch od pottyant l'emmen, odba on todetty henchent da so mabdos artera detta that too olon. Ebed that tpos de porc a p elado hat ay dort bodo dane u bethod od doma Livor butocolo u tom of control polla con importa do Attacher par to, kde a coordened be decat dobte toca la action ported in boll u thermal so layer pouretle bon de bord de tot do por tow you thermo, alord dotonterian padol the time and women I due nulla diputant per te pools moda, da pool toon d'horactions rtereta pe conto per i propri b. The best mod od taton lortutawala po sbobed to the on populasy model oor die beste la tideos con dorty tab 4 103 un potom toda a A JW m (ly bapopatico ao too bamboo contact th d Hosted fotoctists totum mat La otra Watos vento httraite Cocodt, ou cu holda tu ·82 BIDETOLOGY AND CONTROL OF ENDENC SAID Late monofestations ont sigbar to tbox La mandatetico trita sent coop of pandic veneral syphilk, with from nbla i la de la optatis ons que matous lesions on the skin to the mix donciat tekos, rrec kroos pom pharyngeal region, and in the Osteo Dena do 12 pet, de urtica ritmo articular system. Contrary to previous phantasieme a do time orttourticobelie, ocd Investigations brve shown that Latre. La baba at permis diablir lerrohement of the coat) Derydw item gos, contrairement de goe row crusah abo con pro dempet, le rythme derrot central pouvait ere balemcut etteot. Supermfaction of meady infected La rolofaction de cet a fofoctha at and Derde bort k toondered to be the terpiqua et condidito como la prito chic reason for the Croqocess of tertiary arole chose de la fréquence day on letion. When living conditions Improro tertiaira Longos, paralelamcat a l'un ud the comces for pop-maral trany Loration des conditions de vie, la rect miatoo doortas, or ben Infections as do tra non-violticone direct are treated, the oumber of actho tertiary a que la malda cortaden soat truth lezlong dimintba to codec te Thors la Kions tordura activas deicmcort pine their frequency represents an epidemiolo tares dans la mona deadband Leartam Ballader of the state of actity of rur? de fréquence peut donc dit condropres Odende foc ler l'indice deodolad que de lacthis des foyer codeniques en milieu rural It was previously thought that the non Labocace de bons conchiala tult ocurrence of concealal mundfestations Auparmint Coordende comme i po dos was one of the concertatio of cadende característiques de la philis cododque. syphilis. However though nars, they do Man, tout en étant rares, la llons de co occur Thar rarity is largely due to the feme partiendeot parforh Leur rutit fact tha, # Infectiouma to typullis doc, pour beancoap in faut que l'Infoc deauna with the kod stoce in endemic toute de la ryptis doroft trec le temps syphill my yean penerally dip to et come, dans la typhis endereços, de tween the acquisition of the infection and nombre es modes skoulent bobrake tho attainment of matunity that ba Little ment catre I toque de l'enraction a 128 probablity of a mother o print birth to do La murité etk, 1 ya peu de chance congenitally syphillitic child pour qu'ume fede doong dalssance im colmt bérédo syphilitique One section of this paper deal ith the L antear dorit, duos Doe da soctoos orpolation of the field crpalnog em do rapport, rorganisation de la compare phasiztos that are inding was done by antisyphilitique et souligne qua phus des tystematic mologal wreator of the mos cinta, on a co rococo, pour entire population to addition to dnical kokpostage des malades, miro-rdactions Lavettigation, and that follow-op cumin tématiquement éco-chucait commettibile de tions tochded roundag not only La popalation la cremes de cootroke cot treated cha but the remainder of the d'autre part, porté pod sculemot flet otpablo popolation until In , malades traite, mais encore pur ke resto opprobantety 95, of the total coopers de la popolation forceptible d'tut conta population in codem es cumined munde. Dans l'coscrubk, pria do do od 35,20 ara, a of the sound La popoludos tocante cor do comanda populben, maro treated. dans la zona d ademaite dt 2525 malade tot 81 de personnes et stes, at the soumis au mitmeot As the higher Infaction rate u formed Le tu med le plus de tot to north-casteta Bomla, de most botoosivo de obient dans le porte de la Bowl, Beld moet u done in that we cod com cette répoo que coppo ·33 длоY prfarty practice in toploos web i el trebalo date to to Helent proportion duty big b proceso doppa tut ditects of Ibo arder card to pdof back Et contat la plus forte proportion du from the fod to the bord pouble kloms stores, deotipo t cat que pour le proprio do hobude parte da luzes d'thr! The red proolpadta Ola od Il pla do polo protada de td 2% do tronco (AM) hallo nec 2/ do popote dua prored docho ba the compete The obom PAM * costbod dobro tratto date for culturally diction code de lampe, LA 3,000,000 to 4.200.00 ota of TAM Orton dhe do truet pour la comte daly a crery woood dry hai loal of talt trement de l'eduktion too or wo lado. Los recher sobie do 3.400.000 i 200.000 lb CA, however the total down to de PAM rtpordo co ho bodo dagle afection to tu quotidianoas on pratique tous les deux tav v moderna ochar the totul lor. Dans com la de, tout a prea ta con action or ba fot, la don totale di docole o malda Bormal concoquendy the cadeadopted ca o de telection. Aucun doua depended the topopeptal dimettia Il bando de la taun, qon la in the direct een and a de mob doro potuto de tratante en of check food Emputers van tho made ao placo loforthcon lo cota de with high redoos of 1,500,000 da chibo da nema dono do sobor to of PAH, od to a far doned to play on motora pada tanda bacob Do y tallerlar to thom obtuled d'ecce da dhe 2 a A Rocabra with HT doo domable qal y ondeot do depute Oo i aplement tooom, the crpantal, o haloction unico de 1.300.000 mohaan halad obajagudo to chico con don coux du doma po At the agt of the compensa As obeto bampe, on paralt tool than the cities of papeting con la hegou do ponto de la mudho do hoy ha tratacot org but at partout des do pambla dos but becent extent the bry met ba trabuccot, men detta parodno afected penong bo wcped omado corpo prortoght photo de promo la v cm oprettes tuo others obetto con portretuma db renog ocabuttg the deco do Doceda octor d'atra ontodon taid that itglons et des person ploaded mot moy dort bade to decorar badoo Dodot de restrico. L'unicar bractions the one al control Poolte cat port de l'aude om doo, Hd K coopdered Ibo dekor i dupla loomadkaction partiet to hold on bokep Korrels lon dos Sprcaya de condole the other to other ad dotation, parabo du troba o por I do lova damspemoh monts, coordonka dhactloos tortes de contrato po prope a la The totodata mwetta vem La tota la capa Bedshote tatin poportion could poet is de les bom bamboddering the bottle and Panic btk pettro dodol be a better pill popolitica condottog metades Come Hoerer de bedient al costats for their mon and become ta Capados, dos holl dhe ·84 EPIDEMIOLOGY AND CONTROL OF EDELIC SYPHILIS dones encountered u late u fter the second control camination, which indi. ates that prolonged supervision b pocet Ary after organized Deld campagna boxo como to an end. factio stote ont parfoi ho obsah meme uprta lo scoond come do controk, et ce constatations prouvent qumo Rur reillanco coatma demeure nécoral pres que les compage atématiques ont pas The distinction between true relapse or Il not go to pomible, a foochant scrortsunce od dnfection i bardly exclusivement sur des constatations - poudate on clinical or laboratory grounds piques ou serologiques, de distinguer las alone it must be mado Larrely on cpt Yules rochoste on ou do ro-rotanco demiologlal evidence. It w observed de renfortions 11 convteat donc de falro that appurent aura of clinical or rralosaal Larrament appel, cet effet, en donados rebapto or #croresistance were reoenlly éptimologique. It otservó que las found only in those families in whkh a apparents do rectuto diniquo od sro fresh cus of syphilis appeared odwbero Logique ou do stro-resistance aragakol Do all the members with arly typhith uniquement dans la familles od do 100- had beto treated. It wus therefore evident vella fofoctions syphillitique talent that the pitat majority of relapses, or declades et dont tous la marabra treint so-called Totesistant and of corty do typ halb rbcente n'avucnt pas le rooms syphill, were, La flet, reafections ha tretement Il est donc apparu que la pode majorité des rochurtos ou les cos do vphilia récente, atpatta ro-rotanti, Stalent, on fait, des reinfoctious The redaction in the reactor of Infoc On a cottonó que la réduction du racervoir ton wus found to depend largely upon tho do Infection dépendalt dans uno lop aborto treatment of family contacts mere do I administration d'un tratto prch treatment was dren to all persons mcnt abortir un contact fumatlan. Toutes with negativo clinkaal bod scrological les personnes dont l'examen cinque at Andiop who were puposed to Infection rologquo italt nivell neatlr et qui from other menben of ther family Ex Hiquaient détro contradas par d'autres palance with dorape far abortive trout Incmbres de leur famillo oat do soumito moat foally led to tbo adoption of a single de un traitement de comport. Apri l'esal Injection of 1,200 000 anits of PAM. de dones ventes, on fpalement adopté dum cas, mo porologio da 1.200.000 unités do PAH, admłalarta ca o scolo Injection The rotbor consider that, under Exmour L'lateur et d'uvts qu'il est posible, ablo ctrcumstances, and in Iloited ural, par un traitement en mark, do tarir compta It ta poolblo to climinate the rezervor of tement et rapidement lortoerroir de lypfec Infection completely within a short timo tion dans des Dones limites et présentant by mu treatment. In les lavourable das condichoca Invorbier. Lorsque la conditions, the disease can be ctected tod conditions of moins fryonblat, la mala the corvoir roduced to a mio. Over die peut être cartyte et lo racrvoir nedut a longer period ad sypbistan anderio & midim u bout d une périodo plos dhalo an ultimately bo diminated longoa, o bien que definitive, Il est pomiblo de moppemer medialement la syphilis eodémque. In cooclusion, the author patot out that En conclusion, I'moteur indique que lo the program to contra codonk ophis propos de lutte coor La syphilis In Bomba la servdog a bride and to the andémique Borato dalt panetto development of peor public health ser d'umorser i organisation do xura pend roos u the act made are commott nu de santé pobligos, o wront ord's dated Lodood, u bodlated in the i mesure que la could requis root des ·35 FUDLARY band, the fathed btre combated to the drawing-opptur far bod pectal cod pol pablo badith loa ta ta ta oma A dy, como lah mytei propa, les codes fahes ont ouvert be robe à l'atement de plata e dosta tuleb tgloo combaterea do ryto do both publique d' and detailed REFERENCES 1 Almer, P (19.199) Ort, wewe Di 115 2 Amoll, RC, Marcoy LFL Cocher J (1947) Am I Sol 3 264 3. Ano, CD & Loytun, 1930) Amer I SL 34, 324 Beoer T I Wild, L L & Pilen V (1930) J KOT DA. Ipfer. 31, 63 5 Woocok, N. (1930) Mart Sto, Zepirb 6. Brown, WH & Perce, L (191) JAN 03, 353 1 Chemocy A M. (1977) L , battimort I. Chaos A M. & Kern, I E. (1920 op Med. AL, 589 Dete, M. & Gin E L (1930 Su karte i godere da den, ptt 10. Doje, L (197) Glen Hy Zn No. 46 A 314 11 Drup, L (1937) Let Yon 10 12 Expk. H. Magoon, HJ & Factor, L. (147) I am. H. 12. Pager E a Landectoci, ode (1912) Handand der Gachischestremthetsen, Wien & Lepele 14 Motor 1 (172) Man friend 5,4 15. Her (190) Gin Win Ho 5 1 16 Packer, CN & Humor (194) Rruaz Deady where can do to, ale 17 Ott A (1127) Ard. Den dyp, DOL 1,214 IL Gloc, L (117) ► 1 Gra L L (van be a 131 D. OT, LL (1935) Onko. IL Cres, L L (19) Strel 74 1 22. GIS, E L (1937) Sector 11, 239 21. Onc, L1 (193) Det na 3 21 One, EL (0) Lada , 61, 2D 2. Gum, E L (1940) La Vire 24 Grie, L L (HO) Sad. Presse 1-3, 43 n Gr. L L (1447) Za toks 1,4 a. Ocm, L (IHS) Glen Di Na 1,71 » Orie, E L (184) Dringe Hal 3. Grin, L 1190) MZ LO 31 Crte, L L (A Mat Zin LD 12 OstaLL) Anth, 1, 247 ·84 EPDBIOLOGY AND CONTROL OF ENDEDOC SYPINLIS tima cncountered u lato us fter the second control cludmation, which indicate that prolonged fupervision decat ary for organized Beld campalgos beto coone to on cod. faction steento ao porto obserres, memo urta brocood ctia de controle, de constatation procent que por rilance condate demeure desain ra que la campama tyttématiques ant prba The distinction between true rupses or Il n'est patre pondok, or foodant teroristance and rciofection is hardly acturer meat pur da condutthoot diposible on cinkal or laboratory grounds Diquor ou radostanes, de distinguer les uone it must bo medo larpety on Spot males rochutes ou a do ro-resistance derniological cridenice. It was observed da tofaction: il convient donc do loro that appareat and of clinical or geralogical barponent opel i cotellet, mux donndan rolapso or wronhance were generally épidémiologiqua 11 de observe que la found only in thoro families in which cu appurrota do rochute dlo que outro Crash cases of typhills appared and were logique ou de obstanco punolent Dot all the members with austy typhill uniquement dans les familias ou do pov had been treated. It was deteloro evideot Klar forections yphilitiques dualet that the great malority of relates, a Abelardas ct dont tous les membres atteinte so-called stor slotant comes of early do syphilis rheto n'avaient pas soumis typbilk, were, lo (act, renfoction au traitement. Il art dooc apparu qub mode majorité de rechitos og kos om de syphillbs riccote, réputas bordatud, dralent, totalt, dar reinfaction Tho reduction in tho recrroir of mico Onu cum quo Lanthuction du réservoir tlon was found to depend largely upon tho do l'lnfection depeodalt dans mo larp Abortivo treatment of family contacts Metor do I administration d'un tratton arch treatment was given to all persons ment abortir un contacta camino. Tornos with Deptto dunhaal and serological los perronde door laaan dunigoo o fnding who were txpared to infection strologiquo italt ned nepal at gal from other members of their family Ex risculant d turo cootamata par d autres perience with dosages for abortivo treat membros do lear famille ant et sourates ment inally led to the adoption of digte àm trazerocat de coreort. Apbalto Infordon of 1,200,000 units of PAM. de dones diverses, on a finalement adopie, dans cas, uno posolople do 1.200.000 millés do PAM, adalaltata ca une malo Injection The suthor comides that, under Lamour L'actr att d'urta qul cu porsible, ablo drcumstances, and to limited areas, par lm traitent en brie, de tarlr comple It le potilblo to eliminate the terroir of tement et rapidement hertoerrot do 1 unfoc infection completely within short time tion dans des mom limites et présentant by mass treatment In en favourable des condition favorable. Lorsque fos condition, the diseas can be chectod and coodichoma mot motto fryoribles, La mals the reservoir reduced to a miomm over dio peut etre carryte a lo ha toir rédalt a lopper period tod puta us an enderlo 10 minlorum au bout d'amo periodo plo dhcuo cto ultimately bo crpinetod loogue, bien que denttive, il est possible de topprimet ndalonent la ophth ondanique In cooctusion, the author points out that En conclusion, 1 acteur Indqw que la the programe to couro cadetska mphis programo do Jortto cotro la typhills In Bomie trvo us a bridgehood to the anderntque coBoonto dolt petipettra development of pene public-baltbar d morcer 1 orpantation do rien sind rices ut adianco made in congolt rent de coul publiques, qud keront and dated. Lodeod, Lindlated to the i mare que les résultats sequi tuodatto ·ANNEX STUDIES OY TREPONERIES FRONT CASES OF ENDEMIC SYPHILIS TO TURNER, M.D. DAYD E HOLLANDET, LLD Introduction 1. 1950 the Wood Health Orpinization made a pant to Johns Hopkins Valverzity for the establishment of an International Trepoocmatorias Laboratory Center The purpose of the centro wus to study in collaboration whih Belt taims and other laboratoria, certain problems whilch appeared to be bavio to long-robe workhorido attack on the trepoocmatoom. Ono of these probleem ws concetred to be in cucidation of the biological relationship between species and strains of treponemas bobuted from diferent dinical syodroma a tbcy aisted in marious parts of the world. Among the first of much yodroma docted by this laboratory for forekinatoa msaadkami typants, which was then under extensiro Beld stody In Yepoubarba by D L L Go and his sociates, with the support of WHO In collaboration with Dr Grin, two Anims of treponemes from paticata in Boraba ETO fuccedully established in laboratory antraal zod Rubjected to further statyba this laboratory boldoe of Stratos For the attempiod isolation of grains, rabbits and barston at thipped by uber from Baltimore to Sanjero. The transla of bruman material to olmas mus made by Dr Grlo, od the sims were returned promptly by ur to Ballimont, what they were rabacqueatly observed by the waitas. Transfery were made from three patients on 5 September 1950, with rofal toladors fin tro og LADCE. These two strains of thepoocmo buvo been designated a Bosnia And Bosnia B Der Libros VEL, LOLA KAN MULA - 87 - ·86 EPIDELITOLOGY AND CONTROL OF ENDELIC ITAIS 3. Gron, K. (1925) La Jadoobs, J.,od. How do Hag md Geschlostrat writer, Berlin, 17 200 I Gotba, T (1919) A. War Hluk One 235 35 Goths, T & Roypoids, FW (1951) MJ Mone Di 71 1 36. Hackett, CJ (1951) Bore kastom of ow & Uponds, Odord 37 Hodsay, E H (1939) Am y tro Med. 19, 675 * Hodaoc, E H. (1946) Trepantotasis, Now York 39 Hadson, E H. (1951) Br J Peter DL. 2 174 40. rokke o arcode andetag Ho * Bodell Acreeport, 1911 Sıralaro 41 Jukk, Fn Fruno (1850) Prired Batool, Zagreb 42. Klanten, D Kr Rei, CR & Thoms, e W (1950) Act . WOLSimoth 30 3.62 13. Kitchen, DK, Thomas, EW & Reis, CR (1949) J Lrrest Derm12, 111 44 Kolla, W & Prices, R. (1934) Na K, 30, 46 45. Komik, S. (1936) Socled. Prer 33 46. Lopulte, R Z. (1939) Obalhandle centralnog methox Adana kad at master HTML Lo Vulette, Amed Entertatt stes Abodi Hermondd, Zagreb. 121 47 Magorson, J (1945) Amet Med. 3, 611 4. Mapouson, AJ, Bags, H & Fleischman, R. (1945) Amer I Siput 11 49 Magnusson, HJ & Rosen, B. (1945) Amer Sport, 32, 418 50. Merrel, M. (1951) Ant J Sok. 33, 332 51 Morpin, HJ (1941) Aumer 1 Sypk. 23, 233 52. Murray J F, Mentireather A M., Keen, P & Sachs, S. B. (1957) ASAL I. 107 53. Ralum, R U (1952) Lada ned Sc. (in preo) 4. Reynolds, FW, Guth, T & Stemma, G. (1991) J TOMT DE Iporn 17, 263 55 Ron, EK, Györg P & Ingraham, NR (1946) J Pechet 29 507 56. Schamberk L L & Stelper HP (1915) J Wout Dis. Datore. 29 92 37 Sondt, H. (1945) Adu dem ukenrol, Stockt. Suppl. No. 20 58. Thomas, E. V (1919) Sypiar in course and enco, Now York 99 Thoms, EW, Rein, RC, Landy S. & Nice D K. (1950) Amer Spk 3,331 60. Tboos, EW. Rein, R.C. Landy 5. & Kischen, D. K. (1951) Aner Synth 35, 473 61 Urbach, E. & Beerton, H. (1947) Am J Spok. 31 197 62 Vuletk, A. (1935) Ned. Rar. Brak 11, 14 6 Volets, An, ed. (1919) Ende Jakt i Bond i Hororrorid, Zagreb 64. Weinstein, L Dukos, CK & Perrin, TS (1951) LA No. 3, 747 65. Willcox, R R. (1950) Toer De Leon 31, 234 66. Wilcox, R R. (1951) LR 1 383 67 Wright, RD Nicholog, F P & Arpold, R C (1990) or Dus. Idar 31, 235 6 Zos, N (1951) Adam Lagankar S 176 ·ANNEX Carter of the Labor Lotocad la Rabbits The Boseba A and Bogaila B gruins behaved so much alike in laboratory animals that the statements made here will apply to both unless oberwote hodicated Comparisons will be made with noe recently bolted pruns of tepooemd, vell us with the Nichols frain of Treportina pallid which bra beca no widely used in laboratory audiah Among the recently bohated grains, three were solated from patieats with venerally acquired syphilis Chiap, Baghdad , od Beebad B three from patients with beyd Syria Syria B, kod In Blod three from patients with yums Huti A Hald B, and Indonesia B The Bosnia Actrum has pow been through 19 unitoa pessages la rabbats. Of 38 almas Loculted intrutesticularly lessons in which I palabon has been demonstrated developed in 37 The Bosnb B strain has also been through 19 percepatanabbtu u theme of writm L with positively Identified kedons in 0 0 42 udmals Inoculted intratesticularly Trche rabbits have been inocubated Intradermally with the Boma A rum in four it was the role method of troculation in the other sight, it w combined with tealcular moralation Treve rabbits have also been noculated totraderently with the Bognia B grain in foor of these animals thus nus the soto method of loculation. Debied comparative data on these strains will be poblished bcwbest, Sulice it to ay here that the main difference between altbeto strains to In their apacity to produce indmuted kasions to rabbits. Thik, in turn, appears to bo related to the production, perumably by the treponema, of 1 mocord material wuch has been identified as hyaluronic teld. A Rudy of Histopathological material from nabbit kerions thoms do amificant qubicato diference between the Bosnia strains and other typhilis frutos. mottatively borever less poetachromatk maining mocord material ba, ha peneral, observed than with the other typhills Atrim, but much poro than with the yon erald The hypothesla has been annoed' that tho priocipal difference on the sector of the rabbit to the toponenal poup of Orphome resides la the production of hyaluronic add. This difertoco ay lc efter the amount o acopolymbaride produced, or to un atbal chemical duterteco in the hyaluronic iddo produced by different grains and species and a dUCTEDCE to the possceptibility of these prodocus to the cazymes of the nbbit which are concerned with the depoul of hralarooks udd. Un ui attester the blent to which micold matahal is present od loduntod kardom ore produced, both the Bosnia trains copform moro 10 the pattern of that sublied by nebotes ocubated with snips of rexe maly squared myphilis-tbe Nichols, Chicap, Dupdad A, kod Baghdad Banina-than they do to that Ladaced by the infas of yn treporod under sody lodunted lesions of type commonly examined in ryptian ·8.8 EPIDEMIOLOGY AND CONTROL OF ENDELIC MELIS Pagria / strat The patient from whom this stron was obtained was a 35-year-old man, K. A S. History No 86/50 According to Di Gna i noies, the patient had mucous patches under the tongue and on the tonsils popular secondary laions on the face trunk, and extremities, with some becoming pastular and moist condylomata on the genitalu. Kahn und Meinrcko serological reactions were positiva The material for tnoculation of animals was collected, in a mixture of terum and saline from an ulcer on the sbart of the peuus darkfield examination of this material showed many treponemer. One rabbit was laoculated as follows 0.5 ml was injected into the body of ach tests, and 0. el intradermally at each of four sites on the dipped back. One hamster given intradermal Ipoculations Dach side of the scrotum and at four sites on the back, tbc amobot injected at each site being approximately 0.2 ml The animals arrived in Balumoro in good condition on the 70th day after looculation slight changes were poted in each cpididymius of the rabbit and, upon cxasion of tho testis, typical moule treponemos werd demonstrated. This material was transferred to the testes of tovo normal rabbits, which developed lesions in about 30 days. This strain has now been through 19 successive sulmal passagtsNo evidence of infection developed in the hamster inoculated directly from the potent, although the lymph nodes of the hamnet werd not camined. Barla B strain The patient from whom thu strain was obtained was a 38 year-old man, NGO History No 19/50 Four other members of his familyho mfo and three children -- were also infected. Examination of the patient revealed mucous patches in the mouth and moist condylomata lata on tho skin of the scrotum. Material collected from the latter lesions so rerum Aline showed treponemes on darkfield examination The Lahn and Menicko tests were positive Onc rabbit was inoculated us follom 0.4 m) into the body of each testis cod 01 ml cotradermally at four nites on the clipped back Tho animal arrived back io Balamore in good condition On the 76th day after Inoculation lesions were noted in the testes, and on exertion auch showed enlargement of the head of the cpididymis and pinpoint lesions on the aurface of the testis. Transfers were made to two other rabbits, which developed testicular and cuuneous lesions in 21 days. This uncia also has aow been through 19 succesave animal para Bogra C strain Materal 33 transferred to two hamsten only Slace the strain was not recovered from these animals, no further details will be given ·91 A Lobogal Relationship The homologai ratiombiper betrace the Dorty bolated arms od ibe Nichols Arula which my botated in North Ameria in 1911 wero cam- Laad by sudes of chalcopo nocalation Rabatts men trocolated intrtesticularly with the Metro Arto of T ponchen od the animals allowed to progea through the the crolution of the discote Between three und four mouts at the original Locolattos, at time when the animab were knom to be immune to the bomolopous stru, groups of four of these rabbith, topether with four normal nbbio controla, o focolated intradermally on the back with the challenge Arun. Falare of lesions to derdop in the provianty Infected rabbits, when characteristic ledons dandopod In the control, mas regarded as ondance of Rubstantial dagico of crow immity betreon the two gratos Eroploylng the forepołog esperimental method, the following revalts cro oblaksed of loc ulmak preylermity infected with the Nicbob kruin, wono developed besloot opon tenp with 5 000 treponctors of the Bogala A kruha Lajected into each of four etes were four control animals milanty Inocubated developed a chancerbsto pattern of kool The Ane ramolts were obtained when proap of four rabbits immune to the Nichol Aria wa Hendlerty moculated with the Botnha B grain, topaber with fotr Dormil control It be condaded on the basis of tho forcpadog evidence that both of the Bosnia anim in closely related Imunosoboplantly to the Nidols gain Stact AROTO Other typhitis trains baro Uso been shown to bear a similar detonkip to the Nichots strata concluded that the Bomla strada bebare, La this respect, fito most other syphila strutora kolated to vedoms part of the world, bet more particolarty in North America. Pald. Seality Barcla Stribes Laboratory Hodies on the rearterity of a particolar strain of tropo bem co bo Interpreted directly in the of tratment of the dinical diar la patients. Neretheless, laboatory data of a comparative mature Sabe Tory sal wee howed in the light of dinlal perlena with opo of mother of the treponematove The Bosnia anatoa bure beca abjected lo laboratory sady with this point to mind. The penicillin reusittity of these stairs wus tested by lo riro tad to vitro methods. The former la realey crode method derbied to this babonitory' and boy boer wood for tercentag porpora caly Using the Nicol arlo a gandard ordercoce, It has been deletmood that tho botala ring ben tested in the rabbits beste spood to cicathly the aume mama the datace straha od the other serly kolated sypbills ·90 EPIDEMIOLOGY AND CONTROL OF EDELIC SYPHIN were observed to the first to or three passages and, while not all the inoculated animals have shown these typical kalons in rubrequent potragus the Bosala stins unquestionably have the capacity to laduce typuftistike lesions la the rabbit Character and Frequency of Lalons to Hamistos Some years ago Bessemans and de Moor 'noted that, when the golden or Syrian bamster (Alesocrlcetus auratus) was inoculated with T pallidunt, lesions ordinarily did not develop but the animal acquired a symptomless infection as manllested by the presence of readily demonstra blo tropodeunes in the lymph-node. More recently Gaiman' has reported that leshops can bo produced in hamsters by yans treponemes but not usually by syphila straies. In our hands each of the 12 newly isolated strains has at one time or another produced spezic, local ukerated lesions lo hamstay after otra dermal inoculation to the groin or scrotum or into the tissues of the lip. These lesions do not differ significantly in character according to the species of treponemes ipoculated but, from our experience us a whole, it may bo tald that the yaws and bejel treponemes hare produced lessons in a bluber proportion of the hamsters Inoculated than have the Dew syphis traine Morcover mon of tho hamsters which have developed very atensive lesions have been inoculated with either yam or bejel trepodemeh. Sloce a number of factors, much as the temperature of the environment and the uize of the Inoculum have not been adequately controlled it cooot be said at this time that there is a real difference in the behaviour of this animal species to different strains of treponema. Almost without exception, however motle treponemes can be demonstrated in the lymph-nodes of bamsters inoculated with syphilis as hell us with you and bejet trepotentes It of initrent, however that, unlike the lesions induced in rabbits by T pallidur, the lepons in hamsters exhibit little, I any induration, ulthough they aro customarlly swarming with treponemen. What may bo the biological basis of this vartation in the response of these two animal spectes to the same strain of T pallidum is not knowlagala, it is possible that the hyaluronic acid hyaluronidaso system may be lovolved. or eight hamsters inoculated with the Bomla A strain, five developed maternal darkfield-poutivo lesions, and treponemies were demonstrated by darkfield camination of the lnguinal nodos of the other three. The Bosnia B Hrun produced lesions in five of seves hamster hocolated, and each of the other two animals aboned mouto treponemes upon darkfield txamination of the inguinal lympb-codes. These teruits are died as a matter of interest only Hace no conclusions of a compartive nature ao be drawn from theme ·91 Adre Inological Retetico The Imamurologlal relationship between the pealy botated Analns and the Nichob grado what is holstedts North Amela In 1911 were com toed by 1 Rola of alcope loculations. Rabbits and loocolated botn takaluty with the Nichob Anin o T policom und the mimah aoned to progus through the mal crolation of the door. Beteen three and four months after the original boochlatios, ut i tue when the animals were om to bo bamme to the bomologa rin, groups of four of theso rabbits, torethet with four normal rabulo u controls, pero inocolatod totradermally on the back with the college grain. Failure of ions to develop to the previously tafected rabhu, when characterito ladom developed in the controls, nu reprded cridance of a pubstantiu defice of continuity betweets the to trains. Employing the foregoing apperimental metbod, the followiog resulta Pro oborhood of four animab previously miected with tho Nidbob train, Doc developed lessons upon chalcop with 5,000 treponemes of the Bosnia A Ann tnjectod tuto each of four stay, were four control androns dorty tnoculatod dercloped characteristic pattern of lesions. Tho BDO reports were obtained when poup of four rabbits immode to tho Nichols and no menty mocnbied with tho Bomnia B uruta, together with four portal control It be condoded on the best of the foregowy cyldence that both of The Bomla stram no condly related immunologically to the Nichob erute Loco unos other typhilis etratos bayo iko bere sbom to betra dettur relationship to the Nicholas snfinito conduced that the Bomnia Araits belum, la the respect, la mort other typhilis strains isolated to workoms part of the world, but more particularly to North Amela Patch Sasthitty d Berla Stratos Laboratory studies on the road trity of a particular arata of trepo Dout Enot be interpreted directly in terms of treatment of the clintal discreta petieott Nevertheless, laboratory data of a compartimo Datoro ala bo very wral beovered la the Eght of clinical emparicace with ooo O kolber of the utponewstones. The Bosal trata bare been fobacted to laboratory Hody with this point in mind. The pealehtila hivity of these thing was tested by lo vivo and in Vitro wetbode The former to retired code method food in this Laboratory mod bus bete bed for recetat purposes only Uslog tho Nichots #nin a standard of seferter, It has beca determined that the Bosna stralos when taud Lachenbats abasten rapood in aucotially the X met u terdapat grua Lod the other pent bolated syphil's ·90 EPIDERATOLOGY AND CONTROL OF ENDEAC SYTHIN co observed in the first two or three partages and, while not all the inoculated animals have shown these typical lesions in tubsequent papers tho Bospla strains unquestionably have tho apaty to induce syphitis-like lesions in the rabbat. Charter and Frequency of Lesions to Hamsters Somo years ago Bessemans and do Moor? noted that, when the golden or Syrian hamster (Mesocricetus awatus) was inoculated with T polticom lesions ordinarily did not dovelop but tho animal scquired a symptoms Infoction u manifested by the presence of readily demonstrablo treponemas in the lymph-nodes. More recently Gaman bus reported that lesions can be produced in hamsters by yaws treponemes but not usually by syphitis Anjos In our hands cach of the 12 Acwly lolated strains bas at one timo or another produced specific, local, ulcerated lations in hamsters after latradermal Inoculation in the groin or scrotum or into the tistics of the lip. These lesions do not differ significantly in character according to the species of treponemes inoculated but, from our experience as a whok, It may bo said that the gaps and bejel treponencs have produced lesions in a higher proportion of the hamsters inoculated thao have tho den syphilis strains. Morcover most of the hamster which have developed very extensivo lesions have been inoculated with either yan's or bejel treponemah. Suco number of factors, such as tho temperature of the environment and the aizo of tho inoculum, have not been adequately controlled, it cannot bo ald at this time that there is a real difference in the behaviour of this animal spead to differcat strains of treponemes Almost withont exception, bowever motilo treponema can be demonstrated in the lymph-noda of hamster inoculated with syphilis as well as with yan and befel treponemos It is of interest, however that, unlike the lesions lodaced in rabbius by T palliduon, the lesions to hamsten abibit little, If any foduridon, although they are customarily twarming with treponemes What may be tho biological basis of this ranation in the response of these two animal spears to the samo stala of T pallidion is not known again, I possible that the hyaluronic-tod hyaluronidaso system may be lovotved. or cight hamsters inoculated with the Bosnia a strun five developed external darkfield-positivo lesions, and trepotemes here demonstrated by darkfield examination of the inguinal nodes of the other three. The Bosnia B strain produced lesions in five of seren bamsten inoculated, and ach of the other two colmals showed moule treponemos apon darkfield oumioation of the inguim) lymph nodes. These results ar die u a matter of interest only staice no conclusions of a comparative nature can be drawn from them.

·AN 93 micro traT boede et mo acto do to do tota Ndoo totoo Trond Nebol), doat Lapura har trubs of the oa treporomo barvo me do pobrtu w parte do la on to be baby rod kort mim tipookme. 6 bucat prout al trepando led trompo petite De pocha do trpao po wier de qoch altonbedornbentbosters tada tests de bilo do pern til modo polecal relation tip od modo hem traite data The Bowl port deosed the La pochos do Botas prece marder of hy bo polo Koble i la polo malopu i code pe Nichot Analo od odber nccathy be de la moda Nchaba d'etro food Joiny a opah botol or root bottes de otpootale de la trepoucten mphila, da btfel og da Due Tendop cordado thout the Potch A LA ten co that you los moucbre pd boob moral baloes to the per Domo A. Bonde B Appertioco poup of a compartooly mond poupo anal com todorot did Tod that the rapoca to cor Trunki do trust Dewy o poder da odemo spalla poet dora tri par pris le monde podd tobor uch the carpetten les muudattetoda de phob wodemque that burned b perdents with more qou che la malades o tret de syphila Roqda REFERENCES bar, A&Moar, A. de (199) A bu, oso 2. Geom, L M & Mcka, RW (1990 Emo ciganker dina to da edad de tre ord, Wahapon, DC 1 MALE (107face to action pour mettiamo poton, T pertom od troue Bob Hop Urnity Tools) 4. Tra T I ($H Org I (nprw) 1. Trper T & Cumberland, M. C (1949) Evotoplo truder brown Timpo perdem b A some To the yerme ned, Webtoo, D.Com 2012 Two T ... Corsberg, MC & Hi-Yog (197 ANIS 31,776 7 Ton, TA & Horroder D L (1353 Dechanior valorar and make the free ACTE for dhe end not ope) Ne Yock (to be pobinte ·92 EPIDEMIOLOGY AND CONTROL OF ENDEAC SYPHILIS A more sensitive index of penicillin effects is provided by the in vitro methods developed and applied by our associate Mus Elleo Nell. These methods are exstatually those employed in terting other Organisats by the dilution method, with special adaptations to the more difficult problem of assay against the treponemal group of organisms, as described elsewhere." Again employlog the Nichols strain for reference, it has been found that the amount of penicilin which will render 50 / of the treponemes nonnotite in 18 houn, using control tubes for purposes of comparison, is of the order of 0 0019 # per mi of tat material. The corresponding figure for Bosnia A L 00013 and for Bosnia B, 00012 both of which are well with the limits of variation of the method. It is of Interest, too that all other straip, tested fell within these general limits It seem fair to conclude, therefore, that the Bospla strains of endemic syphilos do not very aguificantly in their pernicillin sensitivity from other struna of treponema solated in other parts of the world and from various clinfcal syndromes. These results sugrest that types of penicillin treatment which are found to be effective to other treponemal diseases will be equally cffective in the endemic syphills of Bosnia. Should ugnificant clocal differ ences bo poted between the reaction of the host in endemic syphils and that commonly observed in vedereally acquired syphulus, it appean that they may best be explained by epidemiological or cocological facton rather than by important biological differences in the labortlog treponemies SUMMARY RÉSUMÉ Two gruns of treponema, deslimated Deux pouches do trépondres, depot- "Boula Aud Botnla B were attablah mde Bonnie Act Bosnio B, ootab od la laborutory canals which wero Gown moculées à dos alunor do Laboratoiro from Surnjavo Yo poslavia, to Baltimore, qui ont Hé envoyta per arkon da Sanalero Md, USA, were that boolopaal rela (You postavke) i Baltimore, Md. (Eratt thonhip to pratos bolsted fog othar Unis d Amérique). La neurs ont codil, cllplal yadrones appearing to various 10 Labantotre central loteranulonal dos parts of the world s gudod at the Titpootoutores, la relation biologique International Trepooemios Laboratory abstant cotre ca puchos a ales qu Cooler Both truns went through 19 AKC traient été bolo d autres rypcromos dam contre unimul panies to bot, ind it dilatrentes para du monda. Aprts 19 par mu found that they rotembled ach other mp fucrets tar #bapin, toutes les In un tho cuancteristio poted to thLabo auncherbilques do cotoochas observa ratory Mortover the docu pieturo 2o Laboratotro sont mortes beobque which the strum produced to rabbits and En outre, la manifestations patbotoxiques hustert bud many starcteristics lo cogn ditoretota per chi deur touche de lo moo with that produced by otbe grain bapin a b hamster presentert de Dombreux of Treponad politoon in North Amerta traite colors tree lo qu out at and clicttt produtos per d autres wucha do Thopo * perd en Amérique du Nord et ucun A dote tuntuno lopal relationship mu Uporabilon bumerologique droite a wto demonstrated betwee the Borala pu ttre demostrto catro les souche do ·93 sed recob a TM bosc pecto de toma de Ncholu tab) to HDOT Te(touche Nichots), dont la portad other out of the poorobno me do ponto rooches to hon bobby die Sortios mm théponto platot procé. poto bolated to competents Des Boucles de trlpoolmus bolta do qoch retora behart home ho sbor cou mulda teipts do bife ou de pirn dpadow omgaan doorlop cot mantró bao trote reton TL lato try fomotrated the La spadas de Barilo pritetet e order of city lo peoldha bund ab paletto matapelle te Nahod a od the nice thy bo do pods Nocheb a do pouches We treba biti bald, og stort fokus do tripoolmo du troom mphis, te beje ao do plan The tuon cotode de the Databa LA woms cochant que la de ud bom. Atrain boog both 2012! Boral A & Botole parte coat o poup of the wooooty dood groupo toeru corpo do Tad at the topoon to come Theatret do treho thanty a potrests with a topics met de tri pa pita bohon borld todo mochi tha me parties los mal de conta do syphilis and that ord putlet only qoo de los tulede korrunt de typu Roged type REFERENCES L Laco, A. & Moar, A do (10) L . P . 50 2 Co., LM & McKaRY (1980) Esported to pak dhene la As the lower the you, www.bpton, DC 3. HE L (1990) Student in tracte ponuky, cart the WT padom, T pertensoolonya do Hopit Vauvatty Thesis) Two, T L (SHALWA One the prea 5. Torter T L Combobad, C ( 19) Intermediaciones Troponen mit Aomwarrada per yon neis Weber DCR 2012 TOT Canbeten, C& Homo-Yo L (1947) ARO IS JL, 176 7 Tina T B & Hoodies, D L (1953) Sudes the mediante la carte he and lite Lo The da ACT dari peker hond tot me he Yosh (to be published

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