·The World Health Organization (WHO) is a specialized agency of the United Nations and represents the culmination of efforts to establish a single inter governmental health agency As such it inherits the functions of antecedent organizations such as the Office International d Hygiène Publique the Health Organization of the League of Nations and the Health Division of UNRRA WHO had its origin in the proposal made at the United Nations Conference held in San Francisco in 1943 that a specialized agency be created to deal with all matters relating to health In 1946 representatives of 61 governments met at the International Health Conference New York drafted and signed the WHO Constitution and established an Interim Commission to serve until the Con stitution could be ratified by 26 Member States of the United Nations The Constitution came into force on 7 April 1948 the first World Health Assembly met in Geneva in June 1948 and on 1 September 1948 the permanent Organiza Hon was established The work of the Organization is carried out by three organs the World Health Assembly the supreme authority to which all Member States send delegates the Executive Board the executrve organ of the Health Assembly cohsisting of 18 persons designated by as many Member States and a Secretariat under the Director General The scope of WHO s interests and activities etceeds that of any previous International health organization and includes programmes relating to a wide variety of public health questions malaria tuberculosis venereal diseases and tre ponematoses other communicable diseases maternal and chud health mental health social and occupational health nutrition nursing environmental sanitation public health administration professional education and training and health edu cation of the public In addition WHO undertakes or participates in certain tech nical work of international significance such as the compilation of an international pharmacopoera the setting up of biological standards and of standards for insec ticides and 18 secticide spraying equipment the control of addiction producing drugs the exchange of scientific information the drawing up of international sanitary regulations the revision of the international List of diseases and causes of death the collection and dissemination of epidemiological information and statistical studies on morbidity and mortality

·TREPONEMATOSES
A World Problem
T GUTHE MD MPH
Chief Senereal Dusease and Treponematoses Section
If orld Ilealth Organt Orion
RR WILLCOV MD
Plysretan in charge nereal Disease Department
Aing Edua d VI Ho psal indsor
I ene olagest St Mary s Hospital London
IF HO Treponematoses Con. Homer
WORLD HEALTH ORGANIZATION
PALAIS DES NATIONS
GENEVA
1954

·This publication is a reprint of a special number of the Chronicle of the World Health Organization (1954 8 37 114) NOTE Authors alone are responsible for views expressed in this publication PRINTED IN SWITZERLAND ·CONTENTS Page 5 Changing concepts in the epidemiology and control of the treponematoses Nature and extent of the treponematoses New methods of control 7 21 National and international ach lies in treponematosis control The control of venercal syphilis in Yanous countries Eademic syphilis in Bosnia Bejel and dicbuchwa Mass campaigns against yaws Syphilis control in special population groups International exchange of scientific information International co-ordination of research 33 36 42 46 49 54 57 62 68 Treponemalosis control as a means to an end Consolidation of results Economic aspects of treponematosis control 69 71 Sclective WHO bibliography on treponematosis control 74

·GEOGRAPHICAL DISTRIBUTION OF THE NON VENEREAL TREPONEMATOSES
TIG
Trupi
Corte
201
10
Egetow
10 -
20-
Trepi ved Copelor
Ider
V 6+
W Yaxs Via Pinta
Endemic syphilis and similar conditions
Venereal 3) philis which is more or less presalent throughout the worl! is not shown

·CHANGING CONCEPTS IN THE EPIDEMIOLOGY AND CONTROL OF THE TREPONEMATOSES It has become widely recogaized a recent decades that despite the medical technical social and economic advances of the past century syphilis yans and piota represent a group of infections which continues to aflict a large proportion of the world s population (lig 1) Regions where they are prevalent must be considered as so many reservoirs of world infection exactly as are focs of malaria or yellow fever * 1 Furthermore since the treposematoses are closely related to each other biologically and immunologically and since the causative trepoocmes are all susceptible to peacıllıo there is an increasing demand for a comprehensive world view of these inſections as a group which would replace a parrow approach based on differences in clinical syndromes mode of transmission or other charac teristics pecuhar to one or another From the point of view of public health and of com municable disease control there are definite advantages in the group concept which has in fact gained acceptance by scientists health sorkers and administrators in many coun tres and has been the basis for practical measures taken to combat the treponematoses in different regions of the world over the past few years The study of the natural bustory of the treponematoses and their control require further definition of the relationship between the bost and the parasite on the one hand and the host and his physical soxsa and economic environment on the other hand Sigficant scientific developments and discoveries of recent years have added to our knowledge of these relatioaships and the introducuon of new and more effective bealth techniques has resulted in a basic reorientation in treponematoses control The ssolation in the laboratory of a variety of strains and types of treponemes from Various endemic areas of treponematoses in the world the abisty to maintain treponemes alve on artificial media for some time the production in the experimental animal of relatively tissue free and concentrated freponemal antigens and the discovery of true immobilizing and agglutinating anubodies in the serum--as distioguished from the reagia type of " anti body" determined by usual serological methods--all these advances have greatly expanded our knowledge of the immunological and antigensc relationships among the different treponematoses Since there is no intermediate host to attack in the treponematoses and since immuniza uon procedures are impracticable at the present time the principal approach to treponema tosis control remains case finding and treatment which must be carried out simultaneously with efforts 10 raise the social educational and economic level of the population concerned ud ta H dson L x (936) T por mas NwY $ 116 ·In this domain too rapid strides have been made in recent years The introduction of peni cillin as an effective treponemicidal drug to replace the toxic arsenicals and the development of repository penicillin preparations which will cure a high proportion of early infectious cases with a single injection and which will also arrest the advanced disease have made it possible for patients to be treated on an ambulant basis Penicillin will protect against infection on actual exposure and it is also effective when administered during the incuba tion period of a treponematosis This has permitted the administration of the antibiotic to contacts without overt signs of treponematoses in an effort to sever the chain of infection as rapidly as possible and this procedure has become an important epidemiological technique The triple effect of penicillin-curative in manifest disease preventive or abortive during the incubation period and prophylactic against exposure to contagion-has therefore made it a medical agent which can be successfully used not only in individual patients in clinical practice but also as an important public health weapon for the general improve ment of health conditions by means of mass control programmes wherever the treponema toses are highly prevalent In the two articles which follow the nature and extent of the treponematoses and the new methods for their control are considered in some detail in order to provide background for subsequent sections on what has been accomplished and what remains to be done ·NATURE AND EXTENT OF THE TREPONEMATOSES PIDENNOLOGICAL HISTORY bejel lesions in ancient bones found in the Eastern Mediterranean region has further The question of the antiquity and origa emphasized this problem and bas focused of the treponematoses is one of the classical particular interest on the hypothesis of a controversies of medical history The finding single origin of the treponematoses Accord of syphilitic bones from ancient peoples has iog to this hypothesis one ancestral type given rise to various theones as to the geo of treponeme might through the ages graphical cradle of these infections some gradually have adapted itself to widely sovestigators considering st to be in the differing covrooments in which climatic Americas others in Europe the Near East ethnological Social economic and other or Africa The recent discovery of possible factors have differently conditioned the FIC 2 ANCHEYT SYPHILITIC SKULL FOUND IRAQ The antiga iy of the ! eponerloses has for many years been discursed by medical 1 startans Above is a skull behaved to date from the first half of the first mullersun AD which beary evidence of gumous psico periomar This skult was discovered in 1939 near Zakło Irag by the Government Archaeologust at the time Seron Lloyd In a recent study made in connexion with a WHOIUNICEF bejel-cons of project DSF Kall of Vienna and A De Foe Drector of the Anatomical Department of the Royal College of Medicine Baghdad attribute the pathological changer in the skull to a treponematoris 7 ·treponemes their mode of spread and the out the tropical belt The disease described susceptibility of the host, with subsequent as early as 1519 by Hernan Cortes during development of variations in the resulting the period of Spanish conquest in the clinical syndromes in man Western hemisphere was probably not yaws Whatever their geographical or biological but the blue stain disease, or pinta identi origin the treponematoses have been an fied in recent years as another member of international health problem throughout the treponematoses group history and epidemic outbreaks have been There is historical evidence that many recorded for centuries An infection similar of the recorded epidemics of syphilis perpet to syphilis was known as seamen s jealousy uated themselves as extravenereal infections in Chinese coastal towns in ancient times among children and that this mode of trans and the Biblical plague of Moab has been mission was often mixed with venereal trans identified as syphilis To what extent it is mission among adults The sibbens or possible to identify with syphilis an infection Scottish yaws, of the 17th century after prevalent in eastern Europe many decades the time of Cromwell, was apparently a before the return of Columbus to Europe mixture of venereal syphilis and such syphi from the Americas at the end of the Lis innocens transmitted through drinking 15th century-and of which wooden illustra bowls towels and other utensils and by tions of lesions are still to be seen in Cracow suckling sleeping with infected persons etc Poland--remains under discussion The last case of sibbens was reported in The actual nature and extent of Morbus Britain a little more than one hundred years Gallicus which spread epidemically under ago The Norwegian radesyge of the many names in Europe after the rediscovery 18th century has also been recognized as of the New World by Columbus and sub an extravenereal syphilitic disease and the sequently as a result of the travels of Vasco spirocolon of 19th century Greece and da Gama and other explorers to the Orient Russia was of a similar nature In the are one of the classical examples of an 18th century again Canada suffered out international epidemiological problem Medi breaks of syphilis among Indian tribes at cal historians are still debating whether this St Paul s Bay and Lake Huron where the framboesia like disease was introduced or disease was very prevalent among children re introduced into Europe from Africa when Certain medical and social practices have the slave trade was opened up or whether undoubtedly also contributed to the spread it was brought from the West Indies by of non venereal syphilis over the centuries Columbus and indeed whether it was a An epidemic of syphilis is known to have true syphilitic infection which subsequently resulted from cupping operations at the became modified after its transfer to the public baths in Moravia in 1987 and in ancient world “True framboesia or yaws, France a midwife with a chancre on her as known today was not identified until finger infected 50 pregnant women in 1727 early in the 17th century in the West Indies -an event not uncommon before the inven and in the 18th century in Brazil although tion of rubber gloves In the days before a description was given as early as 1558 artificial milks were used for baby feeding of a yaws like disease among Indian children the wet nurse also contributed to the spread in Rio de Janeiro and other areas of Brazil of the disease For example more than 40 women and children and several men to which it may have been imported from developed syphilis in an epidemic in France Africa Since then yaxs has gradually become in 1752 as a result of infection among wet recognized as an ubiquitous plague through ·10 nurses who had developed nipple chancres may even in developed countries revert to through contact with syphilitic children an extravenereal pattern given a return to Other children in due course infected their conditions of poverty overcrowdiog war mothers and the husbands at the end of or a combination of factors which are con the chain of transmission acquired the ducive to the non venereal mode of trans disease venereally from their wives There mission Thus local outbreaks of asexual are several accounts of the early periods of syphilis among children were recorded in smallpox vaccination in which the arnt Budapest in 1948 and in Chicago in 1949 to arm technique of vaccination is known and were in both instances attributable to to have resulted in the direct spread of unfavourable social conditions On the other syphilis from persons with infectious lesions hand examples may be cited of males from The introduction of the eustachian catheter underdeveloped areas who have acquired was also followed by a number of cases of venereal syphils on visits to large cities and transmitted syphilis Chancres resulting from who have venereally infected their wives on circumcision procedures have frequently been their return to their homes the wives reported in the literature And in modern turn have infected the children non venere times blood transfusion and the tattooers ally and this has given rise under favour needle have occasionally been responsible ing environmental conditions to an epidemic for the transmission of syphilis of non venereal syphilis among the children in the area THE PRESENT PROBLEM Epidemic or endemic syphilis cannot continue to exist by non venereal trans The principal treponematoses -Syphilis mission unless numerous environmental yaws and pinta-are infections resulting factors further this form of spread There is from the interplay of the environment the evidence that with improvement in hygienic human host and the specific micro organism conditions and with general social and econ concerned which may be Treponema palli omic advancement the non venereal type dum T pertenue or T carateum The fact of syphilis bas died out in many parts of that all the treponematoses except sporadic the world although important areas where syphilis are essentially non venereally trans non venereal transmission predominates still mitted has been held to account for some exist 10 Europe the Middle East Asia of the differences (te non occurrence of Africa the Americas and the Western systemic cardiovascular and neurological Pacific Experience in recent years has shown involvement) between them and venereal however that active communtcable disease syphilis but it does not explain the variations control programmes with emphasis on health among the other treponematoses themselves education environmental sanitation and In contrast to those of syphilis the trepo mass treatment with penicillin can accelerate nemes of yaws and pinta are apparently not the social and economic process by which transmitted sexually and the reciprocal the suppression of endemic syphilis-or of partial immunity among the treponematoses any of the other non venereal treponematoses which may represent a natural barrier to the -may be furthered And once the non introduction of venereal syphilis in areas in venereal treponematoses have been sup which the non venereal treponematoses are prevalent will gradually disappear once the latter have been controlled However the Ft E. (1948) Lop) 4 616 ultimate pattern of venereal transmission Exe berg Hik F & Bk AH (1949) D4 Iron 30 7 ner ·treponemes their mode of spread, and the out the tropical belt The disease described susceptibility of the host with subsequent as early as 1519 by Hernan Cortes during development of vanations in the resulting the period of Spanish conquest in the clinical syndromes in man Western hemisphere was probably not yaws Whatever their geographical or biological but the blue stain disease" or pinta identi origin the treponematoses have been an fied in recent years as another member of international health problem throughout the treponematoses group history and epidemic outbreaks have been There is historical endence that many recorded for centuries An infection similar of the recorded epidemics of syphilis perpet to syphilis was known as “seamen s jealousy" uated themselves as ertravenereal infections 10 Chinese coastal towns in ancient times among children and that this mode of trans and the Biblical plague of Moab has been mission was often mixed with venereal trans identified as syphilis To what extent it is mission among adults The sibbens or possible to identify with syphilis an infection “Scottish yan's * of the 17th century after prevalent in eastern Europe many decades the time of Cromwell was apparently a before the return of Columbus to Europe mixture of venereal syphilis and such" syphi from the Americas at the end of the lis innocens" transmitted through drinking 15th century-and of which wooden illustra bowls tonels and other utensils and by tions of lesions are still to be seen in Cracow suckling sleeping with infected persons etc Poland-remains under discussion The last case of sibbens was reported in The actual nature and extent of Morbus Britain a little more than one hundred years Gallicus which spread epidemically under ago The Norwegian “radesyge” of the many names in Europe after the rediscovery 18th century has also been recognized as of the New World by Columbus and sub an extravenereal syphilitic disease and the sequently as a result of the travels of Vasco spirocolon" of 19th-century Greece and da Gama and other explorers to the Orient Russia was of a similar nature In the are one of the classical examples of an 18th century again Canada suffered out international epidemiological problem Medi breaks of syphilis among Indian tribes at cal historians are still debating whether this St Pauls Bay and Lake Huron where the framboesia like disease was introduced or disease was very prevalent among children re introduced into Europe from Africa when Certain medical and social practices have the slave trade was opened up or whether undoubtedly also contnbuted to the spread it was brought from the West Indies by of non venereal syphilis over the centuries Columbus and indeed whether it was a An epidemic of syphilis is known to have true syphiltic infection which subsequently resulted from cupping operations at the became modified after its transfer to the public baths in Moravia in 1587, and in ancient world * True" framboesia or yaws France a midwife with a chance on her as known today was not identified until finger infected 50 pregnant women in 1727 early in the 17th century in the West Indies an event not uncommon before the inien and in the 18th century in Brazil although tion of rubber gloies In the days before a description was given as early as 1558 artificial milks were used for baby feeding, of a yaws like disease among Indian children the wet nurse also contributed to the spread in Rio de Janeiro and other areas of Brazil of the disease For example more than 40 women and children and sercral men to which it may have been imported from Africa Since then yaxs bas gradually become developed syphilis in an epidemic in France in 1752 as a result of infection among wet recognized as an ubiquitous plague through 8 ·nurses wibo had developed nipple chabctes may clen in developed countries revert to through contact with sypkitse children 38 estravenereal pattern gvca retura ta Other children in due course sofected their conditions of poverty Overcron ding war mothers and the husbands at the end of or a combination of factors which are con the chain of transmission acquired the ducive to the pon tenereal mode of trans disease vencreally from their wives There mission Thus focal outbreaks of asexua) are several accounts of the early periods of syphilis among children were recorded in smallpox vaccination in which the aritu Budapest sh 1948 ? and in Chicago in 19493 to-arm technique of vaccination is k2087 and were in both sastances attributable to to have resulted in the direct spread of unfavourable social conditions On the other syphilis from persons with infectious lesions hand examples may be cited of males from The catroducuon of the custachian catheter underdeveloped areas who have acqwred was also followed by a auraber of cases of venereal syphths on visits to large cities and transmitted syphilis Chanctes resulting from who have venereally infected their wises on circumcision procedures have frequently been their return to their homes the wiscs 13 reported the literature And in modern furn bave safected the children non senere times blood transfusion and the tattooer s ally and this has given rise uoder favour needle banc occasionally been responsible ing environmeatal conditions to an epidemic for the transmission of syphilis of con vencreat syphilis among the childres in the area THE PRESENT PROBLEM Epidemic or endemic sypkilts cannot continue to exist by non venereal trans The principal treponematoses syphilis MISSION unless numerous environmental yaws and pinta--are infections resulting factors further the form of spread There is from the interplay of the envirootsient the endence that, with improvement in hygienic human host and the specific micro-organism conditions and with general social and econ concerned which may be Treponema palla omc advancement the non venereal type dum pertenue or 7 carateum The fact of syphilis bas died out in many parts of that all the treponematoses except sporadic the world although important areas where sypbuls are essentially son venereally (385m non vencrcal transsission predominates stal! mitted has been held to account for some EXISZ 38 Europe the Middle East Asia of the differences (10 non occurrence of Africa the Americas and the Westera systemic cardiovascular and acurological Pacific Experience in recent years tuas showa tavolvement) between them and sensreal hon ever that active communicable disease sypaus but it does not explain the variations control programmes th emphasis on health among the other treponematoses themselves education environmental soutation and In contrast to those of syphilis the trepo mass treatment with penicillin, can accelerate demes of yaws and pinta art appartatly not the social and economic process by which transmitted sexually and the reciprocal the suppression of codemic syphils or of partial stounity among the treponeratoses aay of the other noo venereal treponematoses which may represent a patural barrier to be -may be furthered And once the non introduction of venereal syplulis in areas it vesereal treponematoses have been sup. which the non venereal treponematoses are prevalent will gradually disappear once the latter have been controlled However the Feet E. (1948) On imple . 616 ultimate pattern of repertal transmission Euctberg, H Morke, F & Baker AH (1491 rum Dis form, 30 7 2 ·pressed in populations with low SOCIO economic standards emphasis will shift to new problems of disease control VENEREAL SYPHILIS though desirable for each area and country to be fully aware of its treponematoses problem and to include data on infectious syphilis at least in local and national health statistics Even an approximate estimate of the disease problem to serve as a basis for planning control programmes is not always obtainable In applied serology there may also be difficulties leading to an exagger ated opinion of the prevalence of syphilitic infection in tropical and semi tropical areas owing to the fact that seropositivity may be the result of one of the other treponematoses Attempts to secure detailed information concerning the actual extent of the problem of venereal syphilis throughout the world suggest that at least 20 million cases exist although the data available are scattered and not always reliable It is not always possible FIG 3 ANNUAL CASES OF PRIMARY AND SECONDARY SYPHILIS PER 10 000 POPULATION REPORTED IN DENMARK FINLAND NORWAY AND SWEDEN 1919 53 144 12 10 A 1925 1930 19.00 1945 1950 1925 1953 1720 Ondinates rate per 10 000 B-Finland C-Norway D-- Sweden - Denmark 10 ·(true seropositivity) or of false positive se Finland France Italy Poland the United actions caused by non treponemal infections kingdom of Great Britain and Northern In spite of these kimstations fairly reliable Ireland and several other countries although data are available for some countries where it is difficult to appraise the situation accur Senereal disease control has been organized ately since the statistical information is for some time as for instance in the sometimes based only on patient loads at Scandinavian countries where such activities outpatient departments of senereal discase date back to the 17th century In these and chocs which may not directly telect simlar areas where s has been possible to quanlity but rather sndicate a general trend measure trends over a period of time it 18 a given area has been observed that venerea! syphilis The trend of syphilis incidence in the USA remains predominantly an urban disease in over the past few years is of considerable "normal times It anyades rural areas interest particularly in the light of the during times of poverty war and occupation evaluauon made by the WHO Syphilis Study and with migrating populations Following Commission to the USA in 1950 of the every major war its prevalence decreases venereal-di sease-control programme there with a return to normal economic and social after the introduction of penicillin This conditions and with a stabilization of the trend is slustrated in fig 4 and it will be population This decline in prevalence may seen that a rapid dechne occurred in early be accelerated by systematic case finding by infectious syphilis after penicillin had been adequate treatment of cases and through introduced on a consideradle scale educational efforts The incidence of early It is an inherent feature of the problem of syphulss in the Nordic countries as sllustrated venereal syphilis that regardless of general for the period covering both World Wars prevalence geographical distnbution peace an fig 3 and it is interesting to note the or war the majority of early cases occur in syphilis epidemics which occurred there the productive age groups during the war periods and in the immediate ponderance among young females who are post war years The drop in the incidence often infected at an earlier age than the males of early safections was similar in Denmark Tlus age and ser distribution may be seen and Norway after both the First and the 19 table 1 Second World Wars after the Second Despite the rapid decline in the incidence however the rapid decline persisted and of early syphils in several western countries the incidence reached a miatmum level without after the Second World War foci have the long secondary drawn out process which continued to persist in some areas or among spanned almost two decades after the First certain population groups in those countries World War Relaxation of venereal disease-control efforts In post war Germany where military misconcepts on concerning the ease of modern occupation instabilsty of the population and therapy and lack of adequate maintenance many other factors might have tended to of case finding and follow up work may even maintain the cadence of venereal diseases lead to recrudescence of the disease It has at a relatively high level a continued decrease recestly been reported that in 15 States of & the rate of early syphishis has been ex the USA the incidence of syphilis increased perienced following a maximum incidence in IN 19538 Long range planning and sus all three western occupied zooes in 1947 A simlar rapid decline seems to have fal #HMT Org I AS 1950 15 lowed the post war peaks noted in Canada Cutte 1 (1955) Present ton bel me BDA a meeting of Amengad Society for I vestes me Dersnatt with a pre 11 ·FIG 4 CASES OF ACQUIRED SYPHILIS IN THE USA (STATES AND TERRITORIES) BY FISCAL YEAR PERIOD 1941 51 * 70 70 80 6 $0! 40 20 10 10 D ELLI 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 TM 09 TABLE AGE DISTRIBUTION OF 4 145 REPORTED CASES OF PRIMARY AND SECONDARY SYPHILIS IN NEW YORK CITY 1943 Abscissae fiscal year quarters Ordinates thousands of cases A-Late and late latent B - Early larent C-- Primary and secondary D - Congenital Age (years) Number wth primary or secondary syph lis Percentage with primary or secondary syphilis males females total males females total under 15 4 14 18 01 11 04 15 19 306 305 114 09 148 611 1 338 20-24 543 296 37 3 324 795 511 5 n9 88 799 190 198 193 30-34 365 152 517 13 6 104 121 tained efforts are therefore necessary in any treponematosis-control programme As the reservoir of early infectious treponematosis is brought under control by extensive case finding and treatment the emphasis shifts to the late and latent stages of the disease the combating of which becomes a desirable public health objective This is the case in some of the more developed countries in which the former objective has begun to be attained 35 39 76 329 94 52 80 253 195 40-44 37 232 73 25 56 45-49 199 21 48 37 50-54 71 15 86 26 10 21 5 and over 53 6 04 1.8 65 22 145 1000 Total 2,689 1 457 1000 Known mic cases are cl ded 12 ·From the international point of view the at a time when rapid transport by land sea extensive re.crvoir of syphulitic infection and air is now available when desert treks remaining in vast regions 10 several parts and migrations have increased considerably of the world is on the other hand of greater in volume and when commercial intercourse significance particularly in areas where between countries is accelerating under the facilities for diagnosis and treatment are vast economic development and crpansion limited and where venereal-disease-control programmes in many underdeveloped arcas activities have not previously been organized on an appreciable scale For example the NON VEVEREAL TREPONEMATOSES prevalence of venereal syphilis has been reported to vary from 141% to 32 9% of The decline in early yenereally acquired the population in certain areas of Africa syphilis in some parts of the world in recent syphilis surveys in South East Asia have years has called increasing attention to shawn a prevalence of seropositivity ranging the continued custence of endemic hyper from 067 to 31% in different population endemic and epidemic areas of non venereal groups in Afghanistan from 247 to 25 4% syphilis saws and pinta Although precise in Burma from 05% to 119%, in Ceylon statistics are still lacking there is a growing and from 5% to 50% in India in the Eastern realization of the significance of these inſec Mediterranean region recent extensive sur tions as public health problems and survey veys have shown a range in Egypt of from and control programmes - sometimes with 02% to 27/ in Ethiopia of from 421 to international assistance-have begun to give 82% and in Saudi Arabra of from 8% to some idea of their widespread distribution 22/4 and surveys of large population groups and considerable prevalence in the Americas have shown a range of from 12/ to 15/ There can therefore be no Indemic syphilis and soular conditions doubt that millions of cases of syphilis remain in these areas Syphilts has remained an ordinary com It has been found that the prevalence of municable disease in several areas of the venereal infections particularly of syphilis world transmitted non venereally by direct 1s relatively higher in ports than in inland contact and by indirect transfer of T pal cities both in developed and in under fidum among children and adolescents through developed areas This raises the special their play and by drinking vessels and problem of the possible transfer of infection common eating and other household utensils from one country to another and has under primitive crowded substandard con therefore been the object of particular inter ditions of living Non venereal syphilis in its national attention which is exemplified in endemuc form is an infection with epide the Brussels Agreement of 1924 for the treat miological features which have furthered its ment of seafarers in foreign ports (see spread primarily asdong children to such an page 55) extent that the epidemiological term In short although there has been an initial endemic syphilis" has by common usage significant decrease in early venereal syphilis become identified with the mere presence of in some parts of the world since the Second the clinical syndrome most frequently found World War the problem of syphilis continues as the first sign of this childhood disease to be a health hazard in many other regions pamely oral mucous patches Ip Bosnia Yugoslavia such syphilis among children Vaprubhubod sorts of WHO draers or soos liant (1949-57 was widespread uatil very recently and in

·FIG S EXAMPLES
OF MODES OF TRANS
MISSION OF NON
VENEREAL TREPONE
MATOSES
A -- Common use
of drinking vessel
(the Ibrik") in
Bosnia a method
of spread of en
demic syphils
(E I Grin Saraj o)
B- Transmission of sons by direct skin contact of
body surfaces of African miners
CJ Hackett Lod)
C- Chance of the breast. In mother nursing
dichuchka infected child having mucocutaneous
lesions in the oral region
(FMy Jh nocb el

·FIG 6 EARLY LESIONS IN ENDEMIC SYPHILIS Oral mucous lesions of non venereal syphilis (Bosnia) (E. I Gra, Saraye) Similar lesions in “njovera" (Southern Rhodesia) ( RRW licor, Los > the neighbouring republic of Serbia a more endemic syphilis and since they occur in the mixed venereal and non venereal type of early age groups their incidence is different infection was found Prior to the mass from that found in an environment where a treatment campaign of 1948 52 there were an venereal mode of transmission prevails and estimated 100 000 cases (5/) among the two where sexually mature adults rather than million inhabitants of the rural areas of children represent the population at risk Bosnia The high prevalence of infection TABLE II NEW CASES OF ENDEMIC SYPHILIS among children and in the lower age groups BY AGE GROUPS IN A BOSNIAN COMMUNITY in this area is illustrated in table II Age Early There are no essential differences between Cases (fea s) P pulato nt tous per 1 000 the tegumentary lesions of endemic syphilis of pop ton and those of sporadic venereally acquired 0 10 860 120 syphilis in adults and the symptomatology 1395 11 20 1 051 of both includes gummatous destruction of 71 676 the skeleton It is contended that cardio 21 30 842 31 368 vascular and neurological involvement is 31-40 4.2 46 present in the later stages of both But the Over 40 no 276 rarity of primary lesions and of congenital Totel 9909 62.5 manifestations is one of the characteristics of ca 5 2 724 44 15 ·FIG 7 ENDEMIC SYPHILIS IN A HOUSEHOLD OF 19 MEMBERS ( 5 FAMILIES) IN BOSNIA 1951 30+ 37 + 10 Lot 14 18 19 19+ 22 25 23 2+ 0 097 Early secondary lesions Latent Clinically and serologically negative Figures indicate the age of the individual This difference is at least partially explicable on Since the exhaustive studies by von During? cpidemiological and immunological grounds on spirochaetosis in Mesopotamia and there is no evidence of a truc difference in the westward to the Mediterranean were made strain virulence or tissue tropism of 7 pallı in 1896 a condition quite similar to if not dum in endemic or venereal syphilis identical with endemic syphilis has been Studies of the prevalence of endemic described under the name of bejel by syphilis in crowded households with little many investigators in various other parts of living space show that there is a considerable the Eastern Mediterranean region Apparent likelihood of many family members becom ly the condition is of some antiquity but ing infected The age and ser distribution in whatever its origin it is found almost a typical household of this sort where two exclusively among Arabs in remote primitive thirds of the persons living under the same desert villages in Iraq Syria and the roof were infected is shown in fig 7 Hashemite Kingdom of the Jordan where it In small communities the daily contact has for many decades been recognized by the among inhabitants is usually more intense Bedouin as a common childhood and family than in larger villages and it has been found infection Epidemiological and pathological that the more compact the community the descriptions of endemic syphilis and bejel higher the infection rate since there are have also been given in recent years by more opportunities for the transfer of trepon workers in Iran Saudi Arabia and other emcs A survey of 322 Bosnian villages Eastern Mediterranean areas It has been illustrated in the following tabulation shows estimated that this type of infection may a progressive decrease in the infection as afflict a million or more persons in this region the population in the villages increases The early onset and the age and ser distribution of bejel arc similar to what is P 27 Cạp to IN 1d Vulage pop I IN c d found in endemic syphilis (scc table II) 400-600 12.6 less than 200 162 200-400 91 De ing. E. on (1913) Art Derm Sypk (Bel) 693 225 Over 600 16 ·ID The clinical resemblance of the initial sanitation improves This has been demon stages of bejel to those of endemic syphilis is strated 11 in adjacent Iraqı villages inhabited by striking and has been described by a number Kurds and Djibours respectively and where of investigators 8 & 10 The lestons are the conditions are remarkably different usually confined to the skin mucous mem A treponemal infection called njovera branes and skeleton Primary sores are and closely resembling endemic syphilis and extremely rare and involvement of the bezel has recently been described 10 cardiovascular or nervous system in the later Southern Rhodesia among the Karanga stages has not been demonstrated with people in Africa It is contended that bejel certainty in large series of patients although and njovera are identical and that both are random reports suggest that it may occur fact non venereal endemic syphilis It has been stated that the fundamental Dichuchwa has been described by distinction between endemic non venereal McArthur 13 Murray et al and others as syphilis and bejel or bejel like conditions lies another endemic extravenereal treponema in the presence or absence of systemic tosis among the Bantu people of Bechuana neurological and/or cardiovascular involve land it appears to be mixed with venereal ment in the later stages of the disease It is syphilis In both these non venereal trepo still not certain whether such involvement in nematoses--njovera and dichuchwa endemic syphilis may not be attributable to primary lesions are rarely seen except as cases of venereal origin in areas with mixed throw back" transpositional lesions where venereal and non venereal syphilis it is also a nipple sore develops in the mother from debated whether the isolated cases of similar her infected child (fig 5c page 14) The involvement in bejel are due to the same cause combination of darkfield positive mucous Early reports of possible congenital bejel lesions and condylomata is common in both have not been confirmed where it has been conditions which are otherwise character possible to follow for any length of time child ized by the typical history of infection in ren born of women seropositive at preg childhood natural regression or rapid nancy Darkfield positive mucous patches response to minimal treatment typical gum and skin lesions including anogenital condy matous lesions in later life and the occur lomata are common early manifestations rence of the infection as a family and house Most patients go into latency after the early hold disease Definite evidence has not been stages with subsequent development of late presented that cardiovascular or neurological lesions of the skin and bone involvement exists in either njovera or In bejel as well as in yaws and possibly dichuchwa in endemic syphilis there is a seasonal These are examples of non venereal trepo increase in the attack rate with the coming nematoses recently identified in Europe of summer and the warmer weather Prox the Middle East and Africa There 15 imity to marshes or lakes may be among the increasing evidence of the existence in various physiographic factors facilitating the spread other areas of the world of similar foci of of infection in areas with poor hygienic endemic non venereal syphilis or bejel like standards although such factors appear conditions bearing many strange names to play a smaller role as environmental Such conditions have been identified in Hats Iman, C. M (1938) A Dom. Sypka (Chicag) 38 437 Csonka, G W (1953) B #J Dis 29 95 Willcox, R R. (1951) Lorc + 1 558 M Arth D C. (19.3) Amer Syph. 73 M rray J F Merriweather A. M Keen, P& Sachs, SB (195) MdB (Lond) 6 407 H dson, EH (1938) AmeliMd 18 675 W !cor, R. R. (1953) Glarg md J 34 281 17 ·FIG 8 TREPONEMATOSES IN BECHUANALAND valent in and almost exclusively confined to the belt between the Tropic of Capricorn and the Tropic of Cancer (see fig 1 page 4) It is estimated that there are some 50 million cases of yaws in all its forms in the world In the Americas yaws is found in the northernmost countries of South America to only a limited extent in Central America (Panama) and most widely in the Caribbean area It has been estimated that there are some 350 000 cases of yaws in Brazil where it exists in almost every State although it is not a major problem in the southern part of the country The prevalence in 1948 in British and French Guiana was 26 4 and 41 3 per 100 000 of the population respectively It is a health problem in rural areas of Venezuela Colombia and Ecuador Prob ably the highest prevalence of yaws in the world existed until recently in Haiti where more than 50% of the population were afflicted There are reservoirs in the Domin ican Republic Jamaica and Tobago Africa has the largest single continental reservoir of yaws known Conservative estimates suggest that there are about 25 million cases of yaws in tropical Africa In South East Asia yaws is prevalent throughout Indonesia and the peninsula Gross nasophary ngal ulceration of five months duration with history of attack of dichuchwa in child comprising Malaya Thailand and the States hood which regressed spontaneously of Indo China Its prevalence in Thailand (JFM y John brg) and Indonesia where an estimated 12 15 Macedonia Greece Turkey Lower Mon million cases existed until recently is sharply golia Tibet Tahiti India Saudi Arabia decliniog under the mass control campaigns Niger (French West Africa) and the Americas now under way in those countries The They appear to be clinically and epidemio disease is also found in scattered pockets in logically similar and are at least closely re southern India Burma and Ceylon lated if not identical It is suggested that In the Western Pacific region yaws is an appreciable percentage of the population encountered in many islands It is found in is affected in many areas and that the number the Philippines New Guinea and in the Gilbert Ellis Solomon and other island of people at risk is in the millions groups sometimes with a very high incidence Yaws In Australia the irkıntja or boomerang Yaws is conditioned in its distribution by leg among aborigines has been identified physiographic economic sanitary and other as yaxs by Hackett 15 environmental factors and is highly pre Hackett, C. (1930 T art roy Sor i op Med Hyr 30 137 18 ·FIG 9 BONE LESIONS IN YAWS Yaws is a disease of rural areas" at the end of the road " and its jacidence is para doxically associated with the presence of water It is on the one hand recognized that in remote tropical rural villages with little water and limited cleanliness the attack rate of yaws is higher than in areas where water can be used more freely for general domestic purposes On the other hand the attack rate increases significantly with the increased humidity of the rainy season Under crowded and primitive conditions the infection is easily transmitted by direct contact with secretions from infectious lesions and probably also by indirect contact It is primarily a disease of childhood and adolescence Its early onset is illustrated in fig 27 page 72 The primary sore or "mother yaw often appears at the site of an abrasion and is seen on exposed parts of the body such as legs arms buttocks or face The initial lesions are roughly analogous to those in syphilis but those repre senting the different stages of yaws may appear far closer to each other in time than observed among the X ray of boomerang leg aborigines of Australia (CJ Hack Lond) FIG 10 ULCERATING TREPONEMATOSIS LESION COVERED WITH FLIES Purulent secondary infec tions result from fi es under unhyglenlc environmental con ditions (P Kal, Yeon ) 19

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·The manifestations of pinta are usually stigmatized and may sometimes not be not physically incapacitating in the same way accepted for employment in urban areas In as those of syphilis bejel and yaus Pinta this respect the infection is a hindrance to may however become a social and a mental the full utilization of peasant labour in health problem the sufferer from pinta of growing industrial areas or where there is the blue white or mixed vaneties may feel urban development NEW METHODS OF CONTROL PENICILLIN AS A PUBLIC HEALTH WEAPON The management of treponematoses has been completely revolutionized since peni cillia was first shown more than ten years ago to be effective against this class of infection 10 10 and since it was first success fully used by Mahoney and his co-workers 20 against venereal syphilis and then by other workers against endemic non venereal syphilis 21 yaws ? bejel 23 and pinta ? Num erous investigators have demonstrated that the use of penicillin brings about rapid dis appearance of early lesions healing of lesions of the skin and mucous membrane reversal to seronegativity and in late manifestations an effect equal to or better than that ob served with metal chemotherapy Long term studies in syphilis? have shown that when adequate amounts of penicıllın are used adjuvant therapy with arsenicals and bismuth will not improve the clinical and laboratory results (fig 12 page 73) T pallidum is one of the most sensitive micro organisms known As little as 0 0025 unit of penicillia per ml of serum will immobilize 50/ of a given number of trepon emes within 16 hours yet in order to kill treponemes they must be exposed to penicil lin in the blood and tissues for a longer time than most other micro-organisms After intramuscular injection the concentration of penicillin in the lissues increases in a definite relationship to that in the serum and the ultimate concentration in the infected organs is not appreciably lower than that in the circulating blood The amount of penicillin required to kill the treponemes in the host depends on their number and it is believed that they are most numerous in the secondary stage of syphurs before the immunobiological processes have come fully into play and the refractory stage has been reached It has been established that the minimum theore tical therapeutic" penicillia concentration in the blood is approximately 003 unit per mi Although it has been calculated that such a concentration maintained for 96 hours should be sufficient thus treponemicidal level should be maintained for approximately one week in primary and two weeks in secondary syphilis to avoid the risk of any residual treponemes recuperating and multiplying anew It has not been shown that the treat ment of syphilis is rendered more effective by maintaining a higher penıcıllınaemja or RE LIrpool Sch(T pical Med 44 h Ann IR port Agu 1942 ly 31 1943 P 9 Lo de EM&Colle HO S (1943) A Part 37 00 Mah YIF Arn 18 R C. & Harns A (1943) D 1 m 24 335 Gnn, EI (1953) Epid mi Ignd ir mi phi mas 1 to 1 ampign in B1 Genev ( dal Organt.at gr pes N Fundi y GM Hall K & Mauph non, A (1944) Nu (Lo d) 154 795 Akrawi, P (1949) B D 25 115 Rei, CR Kitchen DK Marquez, F & Varela, G (195 Jy ID 18 131 Shafer JR & Usto LJ (1954) B 1 w Os (un press) 21 ·60 47 17 8 665 the corresponding lesions in syphilis Gener carateum was established 17 as the alized secondary framboesides of the skin causative agent of pinta in 1938 The disease and lesions of the bone and joints may is essentially one of childhood and is con appear a few weeks after the initial lesion and tracted early in life by direct and indirect persist for years with intermittent periods contact with infectious cases Its age distribu of apparent recovery and relapse if no tion among series of untreated patients 15 treatment is given The plantar lesions known illustrated in table III as crab yaws are particularly painful Tissue destruction takes place earlier and is TABLE HII AGE DISTRIBUTION OF PINTA a more constant feature in yaws than in IN 665 MEXICAN INDIANS 1952 syphilis Mutilation permanent invalidism and incapacitation for work result in many Number Age (years) Percentage of of cases total infected instances (See fig 9 and 23) Although standard scientific classification 15 90 of yaws lesions and a generally agreed nomen 6 10 143 215 clature must await future action by an 11 15 134 201 international group of experts the First 16 20 115 173 International Symposium on Yaws Control 21-30 143 21 2 convened by WHO in 1952 considered the 31-40 71 immediate need for a simple general group 41 0 26 ing of lesions as a basis for yaws control 51 and over 1.2 projects in the field where lesions are often Total 100.0 recorded by auxiliary personnel with limited medical training this grouping was subse Based on material from Rein CR Kitchen DK quently approved by the WHO Expert Marquez F & Varela G (1952) / Invest Derm 1: 137 Committee on Venereal Infections and Treponematoses 16 Clinical manifestations are confined to the The true clinical course of yaws and the skin and there is no certain evidence of con relationship between its stages are still under genital disease or of systemic cardiovascular discussion or neurological involvement Primary pinta lesions are followed by secondary manifesta Pinta tions with localized and sometimes extensive dissemination as in syphilis These give rise Pinta is a public health problem in Mexico to copper-coloured pigmented areas which and Colombia where approximately 2% turn slate blue Some of the pintides undergo of the population are affected-with an depigmentation over extensive areas of the estimated 250 000 cases in the former and body surface becoming late " or 400 000 cases in the latter It is also found in pinta which represents the terminal stage of Argentina Chile Cuba the Dominican the disease The changes proceed in an Republic Ecuador Haiti Peru Venezuela irregular fashion with recurrence of secon and certain of the islands of the Antilles It dary lesions periodically in the late stages of is not with any certainty known to exist in the disease and with a possible intermingling areas outside the Americas Cases reported of all varieties of dyschromia hypochromia in other regions are more likely to be “pintide and achromia in the same patient Saenz, 3 Gr Triasy, I * Alfonso Armour row (1939) Area Inter Md. & 112 114 Hith Org tech Rep Se 1933 3) white" yaws ·The manifestations of pinta are usually stigmatized and may sometimes not be not physically incapacitating in the same way accepted for employment in urban areas in as those of syphilis bejel and yaws Pinta this respect the infection is a hindrance to may however become a social and a mental the full utilization of peasant labour in health problem the sufferer from pinta of growing industrial areas or where there is the blue white or muxed varieties may feel urban development NEW METHODS OF CONTROL PE ICILLIN AS A PUBLIC HEALTH WEAPON " The management of treponematoses has been completely revolutionized since peni cillin was first shown more than ten years ago to be effective against this class of infection " # and since it was first success fully used by Mahoney and his co workers against venereal syphilis and then by other workers against endemic non venereal syphilis El yaws ** bejel ' and pinta " Num erous investigators have demonstrated that the use of penicillin brings about rapid dis appearance of early lesions healing of lesions of the skin and mucous membrane reversal to seronegativity and in late manifestations an effect cqual to or better than that ob served with metal chemotherapy Long term studies in syphilises have shown that when adequate amounts of penicillin are used adjuvant therapy with arsenicals and bismuth will not improve the clinical and laboratory results (fig 12 Pige 73) I pallidum is one of the most sensitive micro organisms known As little as 00025 unit of penicillin per ml of serum will immobilize 50/ of a given number of trepo emes withun 16 hours yet in order to kill treponemes they must be exposed to penicil fin in the blood and tissues for a longer time than most other micro organisms After intramuscular injection the concentration of penicillin in the tissues increases in a definite relationship to that in the serum and the ultimate concentration in the infected organs is not appreciably lower than that in the circulating blood The amount of penicillin required to kill the treponemes in the host depends on their number and it is believed that they are most numerous in the secondary stage of syphilis before the immunobiological processes have come fully into play and the refractory stage has been reached It has been established that the minimum theore tical therapeutic penıcıllın concentration in the blood is approximately 003 unit per ml Although it has been calculated that such a concentration maintained for 96 hours should be sufficient, this treponemicidal level should be maintained for approximately one weck in pnmary and two weeks in secondary syphilis to avoid the risk of any residual treponemes recuperating and multiplying anew It has not been shown that the treat ment of syphilis is rendered more effective by maintainicg a higher penicillinaemja or ! PM Liverpool School IT op cal Med are 4th A ar part Aut 1942–) ly 31 1943 P 9 Loune, E.M & Cotxer HOT (1943) A Porf 37 .00 Mab Dey J F Am la RCA Harris A (1943) Du in mm. 24 355 EI (1953) Epid ! synd o!!! ad mi palli port on me met ampaign in Boia, Grey ( HI HA Organiza Afonog PAS No 11) Find1 GM Hk & Macpherson, A (1944) A IW (Lond) 154 799 Ak , F (1949) BI D 25 115 Reyn, CR, Kitchen, D K, Marguez, F & Varela, G113321 Evet Dem. 13 137 Sbafer JR & Utd 1 L J (1954) B & W HE OL (ap 1941 ·that there is any advantage in high, intermit dosage is adjusted to their characteristics and tent peak penicillin concentrations in the that the variables in the time dose relationship serum or tissues 26 The early clinical and of penicillin therapy are taken into account laboratory studies were made particularly on Aqueous penicillin G injected several times syphilis but several subsequent studies confirm daily during treatment necessitates hospital that there are no essential differences in this ization and is impractical for physician respect between syphilis and the other hospital and patient alıke It will give treponematoses although certain minor intermittently high blood concentrations and variations have been observed in penicillin a large proportion of the penicillin will be sensitivity among strains of treponemes wasted The introduction by Buckwalter & isolated from endemic syphilis bejel and Dickison 27 of a preparation of procaine yaws penicillin G in oil with aluminium mono- The required penicillinaemia of long dura stearate (internationally known as PAM) pro tion can be obtained with different penicillin vided a practical product which gives a penıcıl salts and preparations provided that the linaemia of long duration when administered Eagle, Fleishmann R & Levy R. (1953) J Lab clin FH & D ckison, HL (1948) Amer ph m 4 37 472 Buckwalt Med 41 122 FIG 11 IMMEDIATE EFFECT OF LONG ACTING PENICILLIN (PAM) IN THE TREPONEMATOSES Whe Maculopapular secondary lesions of saus before and three weeks after injection of 1.2 mega units of PAM (K RHII ki gston, Jamaica) 22 ·100 7100 FIG 12 PENICILLIN ALONE COMPARED WITH PENICILLIN PLUS ARSENOXIDE AND BISMUTH IN THE TREAT MENT OF SECONDARY SYPHILIS 00 80 60 60 10 10 20 20 MAN Abscissae years of observa fron Ordinates cases - Penicillin alone (3 2 mega units) Penicillin (2.8 mega unts) plus arsenoxide (300 mg) and bismuth (600 mg) A - Seronegative B-Re treated B in one or a few intramuscular injections "This has made for a more rational utilization of penicillin from the point of view both of therapy and of economy It is however of paramount importance for the duration of the resulting penicillinaemra that such PAM preparations should have certain minimum characteristics for instance diffusion from the intramuscular depot into the blood and tissues should take place with reasonable and defined slowness notwithstanding the fact that individual variations have been observed in the rates of resorption and excretion through the kidneys Certain minimum physical and other requirements which PAM preparations should meet have therefore been specified by the WHO Expert Committee on Venereal Infections and Treponematoses 28 The desirability of following these interna tional recommendations has been emphasized by the fact that several substandard PAM preparations have been found on the interna tional market These may result in inadequate treatment of patients and excessive relapse rates Recently new repository penicillin salts such as N N dibenzylethylenediamine dipenicillinG and N benzyl B phenylamine penicillin G have been introduced which alone 29 or in combination with other penicillin salts so may give a penicillinaemia for several weeks with smaller doses than are necessary with PAM Under WHO auspices these salts are at present under chinical trial in all the treponematoses in several parts of the world These studies will supplement the relatively few data which have been published on this type of therapy and which have so far been confined to syphilis A report on the first observations of the efficacy of N N dibenzylethylenediamine di penicillin Gin yaws is in preparation Fig 13 shows the duration of the penicillinaemia re Shf JR. & Smuth, C A (1954) B ? WTA Hith Org (Des ) RCRB kw It PH Man CH. La dy SE. FI S (1931) ID 21 495 HUMO brRS 1993 6 35 23 ·It will give that there is any advantage in high intermit dosage is adjusted to their characteristics and tent peak penicillin concentrations in the that the variables in the time dose relationship serum or tissues 28 The early clinical and of penicillin therapy are taken into account laboratory studies were made particularly on Aqueous penicillin G injected several times syphilis but several subsequent studies confirm daily during treatment necessitates hospital that there are no essential differences in this ization and is impractical for physician respect between syphilis and the other hospital and patient alike treponematoses although certain minor intermittently high blood concentrations and variations have been observed in penicillin a large proportion of the penicillin will be sensitivity among strains of treponemes wasted The introduction by Buckwalter & isolated from endemic syphilis bejel and Dickison ?? of a preparation of procaine yaws penicillin G in oil with aluminium mono- The required penicillinaemia of long dura stearate (internationally known as PAM) pro tion can be obtained with different penicillin vided a practical product which gives a penıcıl salts and preparations provided that the linaemia of long duration when administered Eagle H Fleishmann R. & Levy R (1953) J Lab da Buckwalte FH & D kuson, H. L. (1948) J Ame pham Ass 37 472 Med 41 122 FIG 11 IMMEDIATE EFFECT OF LONG-ACTING PENICILLIN (PAM) IN THE TREPONEMATOSES ry the y Afaculopapular secondary lesions of hans before and three weeks after injection of 12 mega units of PAY (KRW Ki Aton, Jam ica) 22 ·page 26 anaphylactic shock in allergic individuals patients in the fully developed secondary have been reported * stage in which larger amounts of PAM are From the point of view of the patient the required to obtain a higher proportion of physician and the dispensary and from that cures In individual clinical programmes of of health insurance systems and health the “urban demonstration and training administrations responsible for clinic pro project type fullest advantage should be grammes and mass treatment campaigns it taken of the properties of PAM using is essential that the treatment besides being amounts of at least 24 to 48 mega units without frequent serious side effects be in the early stages of syphilis In selectie effective inexpensive and capable of being public health programmes against the trepo completed within a short time An assessment nematoses considerations of administration of these four factors in different types of and expense must however be taken into therapy in secondary syphilis is given in account when large numbers of infected table IV persons are involved as in mass treatment The practical advantages of PAM brought campaigos and operational research in out in table IV are undoubtedly responsible for pilot areas has shown that as low a dosage the fact that this is at present the preparation as is compatible with reasonable clinical of choice in the treatment of syphilis and the efficacy can be given in one or a few sessions other treponematoses This was confirmed by a Good results for the majonty must of neces recent worldwidesurvey made by WHO which sity be preferred to perfection for the few showed that more than 80/ of 277 leading It is this calculated risk approach which venereologists and clinics relied on PAM has made it possible for health administra alone in treating early syphilis and by the tions with the assistance of international techmucal discussions at the Sixth World Health organizations to finance and undertake Assembly where PAM for treponematoses large mass campaigns against the trepone control was considered the drug which pro matoses A minimum dosage of 12 mega vided the maximum effect for the minimum units of PAM is recommended for adults expenditure 34 by the WHO Expert Committee on Venereal The medical world requires time and Infections and Treponematoses for the experience to clarify the details of dosage and treatment of the endemic treponematoses administration of any new drug and PAM for venereal syphilis 24 mega units are in the treponematoses is no exception It recommended for primary and 48 mega has been demonstrated in the last few years units for secondary syphilis that a progressive doubling of the dosage of The availability of penicillin is thus the PAM-and consequently of the cost-does key to treponematosis control as was pointed not correspondingly prolong the penicillin out several years ago by the WHO Expert aemia On the other hand the amount of Committee on Venereal Infections In the penicillin required in any particular case early days of its use it was available only lacreases with the number of treponemes at a high cost to the privileged few and many present and while only 300 000 units of other diseases which were more immediately PAM may be needed to cure most cases fatal had first call on the supply Today of early primary seronegative syphilis this it is produced in impressive quantities and amount may cure only some 50/60/ of the totalworld production in 1953 probably ex ceeded 500 tons corresponding to 300 000 000 WINH Lewis, CN kel (1&P m, LE (1953) A!! And CH 3 891 WW HI A Org 1953 7 205 Wld HIIO 1949 15 0 OR 25 ·sulting from intramuscular injections of vari amounts can be administered in one or more ous salts and preparations of penicillin repository intramuscular injections in a In an appraisal of the value of penicillin in single session or if convenient in several syphilis Reynolds 31 stated as early as 1946 sessions On the other hand evidence has that penıcıllın is effective but not always accumulated that side effects may result in a completely so It is in contrast to the metal small proportion of cases in allergic patients chemotherapy non toxic approaching the or in persons sensitized by repeated previous ideal in this respect It is relatively easy to use (or misuse) of small doses of penicillin administer and therapeutically effective Considering that the consumption of penicil FIG 13 PENICILLINAEMIA RESULTING FROM INJECTION OF VARIOUS PENICILLIN PREPARATIONS LO 10 20 40 — А 20 2.0 C 07 07 05 5 07 o ao O DA 004 0 Test dose 300 000 units given intramuscularly Abscissae penicillinaemia duration in days Ordinales penicillin units/ml of serum A - Crystalline penicillin G aqueous solution C- PAY (Procaine penicillin O with aluminiun monostearate) B - Procaine penicillin G aqueous suspension D-DBED (NN diben ) lethylenediamine dipenicilhn G) amounts can be given in a comparatively lin has risen tremendously in all parts of the brief period of time Since then experience world in recent years it is noteworthy both with penicillin therapy in the other treponema that no penicillin resistance has so far been toses as well has steadily grown and it may reported in the treponemes and that side now be said that this statement requires only effects are relatively infrequent and that their little modification to be applicable to them incidence is not increasing being estimated also Indeed it has become clear with the by Kitchen et al 12 at about 37.5%. Isolated instances of death 15 a consequence of passage of time that therapeutically effectie tchen DK Re C R Thom FW & Spo H3 (1951) Amy Sypk 35 378 Reynolds, F W (1946) Amer I Mdf 661 24 ·MIlon: 16 16 mega units of penicillin of which the USA An essential part of international aid to produced some 70/ Penicillin is therefore health administrations has thus been the now more readily available for general use supplying of penicillin for demonstration and with international assistance its bene and training projects and for the first years ficial effect in treating the treponematoses of the mass treponematosis-control cam has been brought to millions of people paigns in underdeveloped areas (fig 14) Further production is planned or BLASS TREATMENT CAMPAIGNS FIG 14 NUMBER OF PERSONS PROTECTED AGAINST TREPONEVAL DISEASES N MASS Since yaws and other endernic non venereal CAMPAIGNS 1948 53 treponematoses are found in rural and underdeveloped areas where medical facılı Million tres are absent or minimal their control requires a communitywide rather than an individual approach aimed at reducing the reservoir of infection as rapidly as pos sible to a level with which existing health facilities in the area can cope Treponema tosis-control efforts in such areas have been based on a wide application of penicillin by the entirely new public health technique of mass treatment campaigns Since there is no immunization against the treponematoses and no intermediate host to attack and since facilities in rural areas are scarce this approach is the only possible one 14 14 12 12 TO 8 0 1949 D 1950D 1951 Dec 1952 Dec 1953 Stages of a Campango Mass treatment campaigns are developed in five main stages at the importance of each being determined by local conditions These stages are (a) general preliminary analysis of the problem (6) development of plans of opera tion (c) demonstration training and survey phase (d) expansion phase-the mass cam paign proper—and (e) consolidation of the programme including its integration into the strengthened local health services An important factor in any mass treatment campaign is the jatral establishment of a pilot or control area in which selected groups may be examined treated and followed up by the different methods under investi Rey , W G the T & Samanie G (1951) wner Do ifm. 32, 263 Eramined Treated Estimated under way in many areas of the worldsometimes with international assistance as in India Chile and Yugoslavia-and it may be said that the world may now have enough penicillin to meet its immediate needs but the demands of many countries are still below the level of medical necessity 27 ·26 TABLE IV COMPARISON OF DIFFERENT TREATMENT METHODS IN SECONDARY SYPHILIS Metal chemotherapy Combined therapy Penicillin alone Assessment factor Ideal therapy Neoarsphena mine and bismuth four 3 month courses of 10 inject ons each Arsenoxide 100 mg by intravenous drip over 5 days Amorphous aqueous penicillin 5 mega units ersenoxide 360-450 mg bismuth 6 12 Injections Penicillin in oil beeswax or with aluminium monostearate 48 mega units bismuth 10 injections Procaine penicilin G with aluminium monostearate 48 mega units NN dibenzylethylene diamina dipenicillin G 25 mega units Therapeutic efficacy 100 915 900 918 864 91 3 940) Toxicity by reactions 0 95 85 3 091 0 12 03 mortal ty 0 0033 05 not reported not reported not reported not reported Conven ence of administration 100 50+ (ambulant) 90 (hospitalized) 65 (hospitalized and ambulant) 75+ (ambulant) 95 100 (ambulant) 99 100 (ambulant) Drug cost 92/8 190 10/4 9/9 10/8 12/6 Based on data from the US Public Health Service the British Clinical Co operative Group and the University Dermatological Clinic Oslo Porcentage of apparent cures at 24 months if the full course is clven and adjusted for estimated relnfections in the case of penicillin schedules with no adjuvant therapy Percentage of serious by reactions Percentage of deaths due to treatment Percentage of patients completing prescribed course of therapy Drug cost to clinics In Great Britain In shillings and pence at 1953 prices Includes seronegative and seropositive early syphilis 21 month follow up ·cases all children at risk under 15 years of with metal chemotherapy Early in the yaws age are included and in areas of very high campaigns penicillin was more expensive prevalence all community members may be than it is now and the total average cost per considered to be at risk and treated as person examined and treated in mass cam contacts paigns has for this reason also decreased Much experience has been gained in these since the inception of the campaigas 38 campaigns and has been detailed in various Nevertheless the cost of penicillin represents technical publications by investigators of approximately half the expenditure per many nationalities It is not intended to person treated in mass campaigas The elaborate on this experience further in the remaining costs concern project personnel present review of WHO activities on tre maintenance of transport and non consum ponematoses control However considera able equipment replacement of consumable tion will be given later to some of the prob- supplies and hundreds of items relating to leras encountered in the expansion pha e of central and field administration the mass campaign to the consolidation of In order to show the total costs and the the initial knock down effect achieved by cost per person examined and treated mass application of penicillin early in control including national and international com programmes and to the integration of the mitments these items are illustrated for three treponematosis control programme into the major mass campaigns in table V The costs general health services of the area per person examined and per person treated have been calculated as averages from the Cost of Campaigns beginning of each campaign up to and including December 1952 as has been The larger part of campaign costs are indicated above these costs decrease as the borne by the governments which are respons campaigns develop For the period ending ible for the projects The costs ate naturally 1952 the cost per person treated ranged higher in the earlier stages of the campaigns from $2 33 to $400 and per person since the initial investment in equipment examined from $0 39 to $0 43 Operational training of personnel and organization is research in pilot and control areas showed considerable that a single injection of a smaller dose of It has already been pointed out (page 26) penicillin could replace the technique and that the drug cost per patient completing treatment is now lower with penicillin than cony S (1953) BHI Wid Hath Of $ 379 TABLE V DISTRIBUTION OF COSTS AND COST PER PERSON EXAMINED AND TREATED IN THREE WHO/UNICEF AIDED TREPONEMAL-DISEASE CONTROL CAMPAIGNS Contribut on (US $) Programine area Cost per pe son e arr ned Govern ment Cost per person f eated (US >> UNICEF WHO Governmet \as de cent gel of total tot i 76 122 24 284 754 4 01 Ph1 pp nes Thailand 369 832 2 9 511 SUB 043 2 76 101 005 662 877 1 59 827 2.356 710 Indones 33,534 19 317 52,851 45 718 310 1 164,264 0 39 85500 139 595 Tot ! 23 330 041 From begin ing of camp lg s to d of 1952 I cludes temporary co sult t only 29 ·page 62) gation and where full facilities are available owing to default or because they were in the for proper serological and other tests for incubation period at the time with patients the recording of results and for epidemi who have relapsed or with persons who have ological evaluation The experience gained recently migrated into the area At these from such operational research In the resurveys it is necessary to examine the pilot or control areas may then be applied entire population again Experience in 10 a more general fashion to the campaign Indonesia and elsewhere has indicated that area as a whole and the principles established most of the infectious cases discovered in the there put into practice in projects elsewhere villages that were re examined would have At the outset little experience was available been missed if the group originally treated on how to conduct mass campaigns but had been the only one studied It is con now as a result of work done by health sidered therefore that in order to obtain a administrations and WHO experience is lasting effect in mass campaigns against yaws steadily mounting and there can be little the entire population should be resurveyed doubt that the investments in such opera at intervals of approximately one year in tional research will pay practical and scientific areas of initial high prevalence of infection dividends as the wider programme develops a point which will be discussed later (see 3 It is necessary to give preventive or abortive treatment to contacts Experi ence in Haiti Thailand and Yugoslavia has emphasized the importance of treating con Conduct of a Campaign tacts who may have no overt signs of disease Several important lessons have been In the treatment of venereal syphilis this learned from the mass campaigns which have matter 1s still controversial although been carried out in recent years Alexander et al 37 have demonstrated that penicillin can afford almost complete pro 1 It is desirable in a mass campaign to tection to persons exposed to the infection eramine the entire population If this is not However there is no doubt that in the done some infectious cases will be missed endemic non venereal treponematoses es and the campaign may fail Experience in endemic syphilis and yaws the treatment of Haiti has shown that the entire population apparently non infected contacts with penıcıl cannot be examined by setting up permanent lin is not only an effective but also an essen clinics and relying on the voluntary attend tial epidemiological procedure Without it ance of the patient Even with suitable control campaigns may in the long run fail propaganda less than 50% of the population not only because persons in the incubation may be reached If mobile clinics are also period will later develop the disease but also provided in strategic areas this figure may because latent cases which remain undetected increase to 70/ and if a house to-house when no serum tests are made may relapse survey is made the percentage will be 90 or Contacts have been differently defined in more It is now appreciated that a house to different campaigns according to the prev alence of the disease and to environmental house technique is the best method of case conditions In some cases a limited definition finding for most mass treatment campaigns has been used the term including only 2 It is necessary to revisit an area after members of infected households in other mass treatment. It is evident that follow up examinations are essential in order to deal A drLI Schoch AORM Looth WB (1949) with cases missed at the first examination Amer Sypl. 33 499 28 ·dosage initially used in several of the mass table is thus far less precise However the campaigns provided that the PAM met significant long range commitments of health WHO specifications A saving of 34% in the administrations in treponematosis control expenditure for penicillin was thus effected may in general be illustrated by fig 15 and operational costs were also reduced by which shows national and international the simplification of campaign procedures funds expended or allocated during the The cumulative effect of this and the other five year period 1949 53 It will be noted that factors already pointed out above has the information is given by type of project and permitted the forecast that the cost per category of expense for mass campaigns for person examined and per person treated in demonstration and training projects and for such campaigns will drop to $0 10 and projects with emphasis on the control of $100 respectively in 1954 prenatal and infantile syphilis all of which Information concerning the costs of cam are discussed in the following section paigns other than the three listed in this 31 ·FIG 15 NATIONAL AND INTERNATIONAL FUNDS FOR TREPONEMATOSIS CONTROL 1949 53 US $ xil on + A B A - Demonstration projects B - Maternal and child health senereal disease projects C - Mass campaignis International expendi ture by type of project and source of funds D- D T. Transport } REG u CEF E E - Laboratory equipment and supplies F - Personnel International expend! fure by category of expense and source of funds F G - Penicillin P8 mm US $ Il en TAP Tech / 14 ist RLG R&I Budg Governments 51 5% $ 6 894 585 National expenditure average percentage in four major campaigns used as basis for calculation of national expenditure In total programme International og nizations 48 5% $ 6 405 512 010) 30 ·NATIONAL AND INTERNATIONAL ACTIVITIES IN TREPONEMATOSIS CONTROL Since the Second World War a number of governments in various parts of the world have wished to take advantage of and to participate in international co-operation for the control of the treponematoses This international co-operation has taken several forms First many health administrations which have attacked the treponematoses problem with new control methods based principally on case finding and on penicillin treatment of cases and contacts have found it desirable to draw upon the experience and advice of health workers in other countries through the medium of WHO and upon the co-ordinated assistance of WHO and UNICEF in providing supplies and equipment not locally available (eg Indonesia Haitu Thailand) The technical ard of WHO under its regular budget or under the United Nations Technical Assistance programme is frequently given to develop mass treatment campaigns described previously as a new public health techaique in the control of the treponematoses A second type of activity has been the establishment or strengthening of demonstration and training projects This has in the past proved a useful form of international health and and some countries (eg Ceylon Egypt India) have developed projects based on this approach A well-equipped venereal disease centre is established as a model for others to be set up later in different areas by local health administrations and to serve as a training base for medical and auxiliary personnel Such a centre or clinic is usually directed and operated by national staff assisted by an international team of advisers which may include a venereologist a serologist a public health nurse and sometimes a health education specialist In addition to diagnosis and treatment the activities comprise epidemiological measures including case finding through home visiting Serological services not only are used for diagnosis and follow up of cases treated in the centres but also are applied to special wider samples in different population groups and in other parts of the country as the project develops The demonstration and training centre is usually in an urban area and is in a way supplementary to the mass treatment campaign justified 10 rural areas in which facilities are mobile and activities simplified because of the prevalence of the treponemato and the more primitive conditions of health and onment in which it is carried out A third approach has been adopted in some countries with special problems of syphilis control in these as part of the general health programme advantage has been taken of maternal and child health services in order to find cases of syphilis and to give treatment to children adolescents pregnant women and nursing mothers This approach was used in Finland and in some of the eastern European countries immediately after the Second World War In other countries such as Afghanistan Burma Pakistan and Taiwan venereal disease control has been further emphasized in the maternal and child health programme by having a special section on venereal disease control within the framework of the activities of the WHO advisory team 33 ·FIG 16 NATIONAL TREPONEMATOSIS CONTROL PROJECTS INTERNATIOVALLY AIDED UNDERTAKEN 1948 53 OR PROJECTED 1954-55 ZE M233 campaigns Demonstration and training projects Projected 1954 55 ·tological Congresses and the International Union against the Venereal Diseases-the programme of pational health administrations and WHO may obtain support from voluntary organiza tions and professional societies in many countries WHO maintains official relationships with the laternational Union against the Venereal Diseases and various joint projects have been undertaken such as the publication of information on pational venereal-disease legstation throughout the world These various phases of the Organization s work will be considered in the articles which follow though it must be emphasized that only a general review can be given here and that this account does not claim to be a complete catalogue of national and international treponematosis control activities Further information concerning national projects and WHO s programme in treponematosis control may be found in the medical literature including other WHO publications such as the Bulletin of the World Health Organimation the Monograph Series the Technical Report Series and the Oficial Records of the World Health Organization including the Annual Reports of the Director General WHO OBJECTIVES IN TREPONEMATOSIS CONTROL 1 To stimulate the development of intensive and comprehensive health projects so that the treponematoses can be eliminated as public health problems and by such projects to contribute to the strengthening of local and national health services 2 To contribute to the establishment in Member States of a practical degree of control of vepereal syphilis and other vencrcal 1fections) and to the prevention of their spread between countries and within special population groups 3 To stimulate teaching and training activities to promote studies and exchange of scientific information to foster simplification and Jon of health techniques through operational and laboratory research, in an effort to co-ordinate national and international treponematosis-control activities 35 ·The above aspects of treponematosis control call for special national efforts and long term commitments under the communicable disease control programmes of the countries concerned WHO s role is to meet the governments requests for technical aid through its machinery of regional offices advisers and consultants assigned to specific projects In the five years from 1948 to 1953, WHO has assisted health administrations in many countnes and in all regions in treponematosis control Fig 17 illustrates the expansion of the programme on a geographical basis for muss campaigns and for demonstration and training projects The expanding nature of internationally arded programmes in terms of the increasing number of persons protected against the treponemal diseases 10 mass campaigns during the past several years has already been illustrated in fig 14 (see page 27) FIG 17 TREPONEMATOSIS CONTROL PROJECTS ASSISTED BY WHO AND UNICEF 1948 53 i i BECHUANALAND LIBERIA LAOS PARAGUAY PARAGUAY INDIA IU INDIA IN PHILIPPINES PHILIPPINES ECUADOR 11 ECUADOR E IRAO IRAQ THAILAND THAILAND HAITI HAITI PHILIPPINES INDONESIA INDONESIA ECUADOR II YUGOSLAVIA YUGOSLAVIA IRAQ GUATEMALA TAIWAN THAILAND ROTTERDAM GUATEMALA ECUADOR I HAITI S ARABLA ROTTERDAM KRAQ INDONESLA PAKISTANI 6 ARABIA THAILAND ECUADOR 1 RAN PAKISTANI HAITI YUGOSLAVIA INDLA E TAN INDONESIA BURMA ETHIOPIA INDLA II YUGOSLAVIA CEYLON BURMA ETHIOPLA YUGOSLAVIA POLAND EGYPT CEYLON BURMA POLAND AFGHANISTAN AFGHANISTAN EGYPT CEYLON INDIA INDIA 1 ENDLA 1 AFGHANISTAN AFGHANISTAN 1949 1950 1951 1992 1950 O 070 A-- Demonstration and training projects B-Mass campaigns Romi nun als ind Imo e than project in the sm ry POLAND 1948 In addition to aiding national efforts such as these WHO has a more directly inter national function in co ordinating and stimulating treponematosis control on an inter-country and inter regional basis As an international co ordinator of health activities WHO also grants fellowships sponsors training courses organizes seminars symposia and international conferences encourages the exchange of scientific information provides technical guidance through its expert committees furthers the standardizalion of serological reagents and methods co-ordinates special studies on particular treponematoses problems and under takes operational research aiming at the simplification of health techniques Finally through collaboration with international non governmental organizations inter ested 10 venereal disease and treponematosis control-such as the International Derma 34 ·tological Congresses and the International Union against the Venereal Diseases-the programme of national bealth administrations and WHO may obtain support from voluntary organiza tions and professional societies in many countries WHO maintains official relationships with the International Union against the Vedereal Diseases and various joint projects have been undertaken such as the publication of information on national venereal-disease legislation throughout the world These various phases of the Organization s work will be considered in the articles which follow though it must be emphasized that only a general review can be given here and that this account does not claim to be a complete catalogue of national and international treponematosis-control activities Further information concerning national projects and WHO s programme in treponematosis control may be found in the medical literature including other WHO publications such as the Bulletin of the World Health Organi alion the Monograph Series the Technical Report Series and the Official Records of the World Health Organi ation, including the Annual Reports of the Director General WHO OBJECTIVES IN TREPONEMATOSIS CONTROL 1 To stimulate the development of intensive and comprehensive health projects so that the treponematoses can be eliminated as public health probletns and by such projects to contribute to the strengthening of local and national health services 2 To contribute to the establishment in Member States of a practical degree of control of venereal syphilis (and other venereal infections) and to the prevention of their spread between countries and within special population-groups 3 To stimulate teaching and training activities to promote studies and exchange of scientific information and to foster simplification and standardization of health techniques through operational and laboratory research, in an effort to co-ordinate national and international treponematosis-control activities 35 ·THE CONTROL OF VENEREAL SYPHILIS IN VARIOUS COUNTRIES Eastern Europe Patients with early syphilis received 342 Aid from UNRRA was requested by mega units of penicillia in ou beeswax (POB) several health administrations in eastern -the repository preparation available at that time in the early stages of the campaign Europe after the Second World War Some this treatment was combined with a course of these requests were for assistance in the of arsenoxide and bismuth Pregnant women control of venereal syphilis which had become a serious health problem in many recerved 6 mega units of POB without adju areas as a result of the war With the cessa vant therapy and children with congenital tion of UNRRA activities this type of and syphilis also received penicillin alone Four hundred and thirty five physicians became the responsibility of WHO and UNICEF which provided technical advisers 331 nurses and 255 public health nurses and and consultants and certain supplies and social workers were recruited training equipment to the Governments of Bulgaria courses were open to all physicians in the Czechoslovakia Hungary and Poland for country syphilis control In some of these countries The Polish mass campaign was from the start integrated with the health services emphasis was on the control of prenatal and infanule syphilis but in Czechoslovakia and which in effect were responsible for the Poland the control measures were of wider organization of new treatment facilities it also made use of the existing venercal disease scope clinics local health centres and maternal One of the first treponematosis control and child health units projects in which international assistance was sought was in Poland The Polish health Unfortunately Poland has since 1950 ceased to be an active member of WHO administration undertook a syphilis-control and precise information for evaluating the campaign in which penicillin was used for ultimate success of the campaign has there the first time on a mass scale In 1947 mobile units were established for fore not become available to the Organiza case finding by mass serological screening tion The same is true of Bulgaria Czecho examinations and for the health education slovakia and Hungary from which sufficient data have not been obtained to appraise the of the public The entire population of the actual extent of the work and the results arcas concerned was examined and positive achieved reactors were directed to the nearest health centre for confirmation of the diagnosis From the start of the campaiga unul the end of August 1948 1 540 000 persons were Finland Greece, Italy examined by the Chediak test which was found the most practical for mass screening The programmes in Finland Greece and of the 1 200 000 persons examined duriog Italy were designed to assist the Governments 1948 alone 21 772 Dositive or doubtful of these countries in the control of syphilis 11 066 were among pregnant women nursing mothers confirmed by and infants Equipment and supplies were serological find 2 36 ·provided by UNICEF and consultant ser In Italy demonstration centres were estab vices medical literature and fellowships Jished in Rome Naples Palermo Messina by WHO Catania and Agrigento In the centre at In Finland control of prenatal and infan Naples work began in 1948 but activities tile syphilis formed part of a nationwide did not start in the other centres until the venereal disease control campaign which early autumn of 1949 By the end of 1950 although well organized and operated was 15 613 serological tests in prenatal syphilis restricted owing to economic and technical had been carried out and 1 074 in cases of difficulties International assistance enabled infantile syphilis 2729 patients had been the Government to expand its efforts and to treated with penicillin 2 181 of whom were introduce modern methods of treatment and pregnant women control on a wider scale The proportion of In 1950 the Italian Government distributed pregnant women serologically examined for penicillin to all venereal disease control dis syphilis increased from 41/ in 1946 to 92/ in pensaries in major towns in Italy 1951 and the total number of blood speci In Greece the Ministry of Health requested mens examined by the serological labora WHO/UNICEF assistance in 1949 to control tories in the country increased from 288 885 syphilis among pregnant women in Athens in 1949 to 323 135 in 1950 an increase of Piraeus and Salonica During 1950 and 1951 about 12/ The great majority of syphiletic about 1 510 women and a similar number of mothers were hospitalized before delivery congenitally syphılıtıc children were treated for complete physical and serological examin with penicillin In 1950 a demonstration ations post natal examinations includ project for treatment of early syphilis in ing X ray studies of mothers and chil adults was established with WHO assistance dren were carried out at stated intervals in one of the major clinics in Athens Although the specific death rates attributed to syphilis have shown little change a significant reduction took place in infant India mortality due to syphilis in the period 1948 51 Despite the considerable decrease A WHO venereal disease demonstration in the number of discovered cases of primary team began work in the Himachal Pradesh and secondary syphilis in the country as a in 1949 with the aim of developing venereal whole venereal disease control activities have disease control on modern lines at reasonable not been relaxed it would appear that so cost and of giving training in diagnosis treat long as these efforts continue it is not likely ment and control to local staff Laboratory that venereal disease will again be a public centres for bacteriological and serological health problem of great magnitude This procedures in the diagnosis of venereal shows how appropriate aid to an already disease were established and stress was existing and effective venereal disease control laid on the standardization of serodiagnostic programme can sustain and expand public techniques health activities Treatment schedules were recommended In Greece and Italy no nationwide vene suited to local conditions and the import real disease campaigns were envisaged After ance of controlling early infection and of visits by WHO consultants it was agreed preventing congenital syphilis was emphas that limited demonstrations of case finding ized Due attention was also paid to the and of treating prenatal and infantile syphi desirability of special research work the Iis with penicillin should be undertaken compilation of statistical data and the value 37 ·of epidemiological investigation and case ening of the facilities for teaching and finding research at the Venereal Disease Depart Training was given in three month courses ment of the Madras Medical College The and the most satisfactory teaching method clinic there is probably one of the largest was found in seminars technical demonstra in the world total attendance in 1949 tions were carried out in the clinic the amounted to 69 939 men and 20 320 women laboratory and the field and children and in 1950 to 66 092 men During the first year serological surveys and 24 131 women and children In both years were made in many areas in different parts the number of new cases erceeded 15 000 of India Wide variations in seropositivity WHO has supplied a consultant serologist of from 5% to over 50% of the population and a public health nurse in addition to groups examined were revealed laboratory and teaching equipment and a A limited mass campaign was undertaken medical social worker has been provided by in the Ghund area where the prevalence of the United Nations The Madras Govern syphilis was found to be extremely high and ment has for its part considerably increased where environmental conditions were such its staff and provided equipment and supthat the project could be subjected to certain plies for the further strengthening of the controls Altogether about 1 556 persons medical centre were tested by the Meiniche and VDRL A special laboratory established in the slide test techniques and 590 persons (38) Madras General Hospital participated in the were treated in 1949 with 300 000 units of first all Indian serological evaluation pro PAM each A sample re examination of gramme sponsored by the Indian Council 453 persons was made six months later and for Medical Research Six national labora of 177 after a year tories in different parts of India participated Experience in this small pilot project and the Madras laboratory acted as reference indicated that large groups of people could centre Inter state evaluation of the tests be assembled for examination and treatment performed by field laboratories was also under extremely difficult field conditions and organized that if simple slide tests were used laboratory examinations also could be carried out in the field and the results of the serum tests Afghanistan obtained on the same day as the specimens were taken The immediate results of treat A venereal disease clinic and laboratory ment indicated a satisfactory initial decrease working in co operation with maternal and in the reservoir of infection and the number child health services was established in 1950 of new cases fell significantly? At the follow at Kabul WHO has provided medical up examinations a considerable lowering in advisers and nursing consultants and the serological titre was also noticed and UNICEF has provided important supplies А Between March 1952 and July 1953 seven the re treatment rate was about 20% medical officers and nine nurses were trained resurvey for epidemiological study is planned in the venereal disease clinic cight medical officers 24 laboratory technicians and assist A demonstration project in progress in ants and four nurses were trained in the southern India is concerned with the strength laboratory Lecture courses have been given to the local midwifery school to student nurses at the maternity hospital and to Cuiler JC, et al. (1962) Bull w/ Husk Org : 377 for 1955 40 ·medical personnel at the kabul military in the campaign in Manta A third campaign establishment was organized in Bahta in May 1953 Numerous serological surveys have been undertaken and treatment has been given to patients with positive reactions Home Egypt visiting and epidemiological case finding have been encouraged A total of 5 153 persons With the help of WHO a demonstration have been tested and the seropositivity has centre was established in 1950 at Tanta varied from 31/ among prisoners at Herat between Cairo and Alexandria with the to 06/ among schoolchildren in different objects of furthering training of medical and areas auxiliary personnel of standarduing diag The laboratory has gradually increased nostic and treatment procedures of stimulat its activities from serological testing for ing interest in the promotion of health educa syphilis only to include various laboratory tion of encouraging case finding epidemi examinations of a general character in fact ological and other public health methods of it is currently functioning as an expanded carrying out operational research and public health laboratory for maternal and finally of studying the importance of the child health and other purposes venereal-disease problem in the country as a whole It was found that the incidence of syphilis was not as high as had originally Ecuador been estimated by the health administration The seropositivity among different popula In Ecuador a small scale demonstration tion groups totalling 29 704 persons varied for controlling syphilis by mass PAM treat between 173/ and 02/ ment has been in operation in the Portoviejo The demonstration centre was later trans and Manta regions since 1950 Each of these ferred to Cairo where the international staff regions has a population of 5000-6 000 per (a venereologist laboratory physician public sons between the ages of 15 and 50 years health nurse and a health educator) was able All persons in this age group whether or to enter into more direct contact with upi not they were infected with syphilis have versity clinics and to create interest in health been given two injections of 1 2 mega units education The demonstration team intro of PAM each at five days interval and a duced and gained wide acceptance of the serological test has been made at the time use of PAM in syphilotherapy in national of the first injection the patient being clinics throughout the country newer antigens informed of the results at the second injec and modern serological methods were also tion Treatment has been given in the central introduced Training courses were organized chinc at community centres and on a mobile by the Ministry of Health for doctors nurses basis by a house to house canvass By this and serologists Mobile venereal disease a mass treatment campaign and a control field units were established serological survey have been conducted The WHO team left Egypt at the end of simultaneously 1952 However venereal disease control 15 By September 1952 VDRL and Kabn going forward and is being extended Thus serological tests had been done on 4 762 per a mass serological examination of the popu sons in Portoviejo 404 (8 5/were positive tation of the Siwa oasis in western Egypt was to both tests Up to March 1953 some recently made patients and contacts were 7 223 people had been serologically tested treated and the epidemiological and socio means 39 ·logical aspects were studied The population of a venereologist and a public health nurse of this oasis is being re examined after six It has been estimated that venereal diseases to eight months This is an example of the affect more than 10% of the total island kind of continuity which WHO seeks to population ? foster when its direct assistance has ceased A model clinic was established in Colombo to start the control of venereal diseases in Burma the city Collaboration is maintained with other medical and public health activities A model venereal disease clinic and lab such as maternal and child welfare clinics and oratory has been in operation in Rangoon blood banks Three local subsidiary clinics since 1951 with WHO and UNICEF assist and four outstation clinics run by medical ance The clinic works in co operation with officers trained at the main clinic have been five local venereal disease centres and four set up in different parts of Ceylon Between venereal disease centres in other areas of March 1952 and November 1953 4013 cases the country have been established as part of syphilis were diagnosed among 22 479 of the project There has also been close patients seen at the central and other clinics co operation with maternal and child welfare Special serological surveys have been con centres throughout the country and with a ducted on a total of 46 853 persons who special skin clinic for the treatment of leprosy showed a seropositivity varying from 11 97 Between September 1951 and December among workers in private tanneries to 0 59 1953 a total of 34 571 cases of syphilis were among schoolboys found among 118 446 patients seen at the Since June 1952 a number of medical main clinic and the outlying clinics including officers have been trained at the clinic and those in Mandalay Moulmein and Pegu courses of lectures have been given to A pumber of special serological surveys have doctors postgraduate and undergraduate been undertaken in which 39 378 persons medical students sanitary inspectors nurses were tested The seropositivity varied from rural leaders and teachers from the training 25 4% among Rangoon port workers to 24% school among Rangoon students At the Rangoon centre medical officers Ethiopia nurses Inspectors laboratory technicians and social workers have been trained by the On the basis of recommendations resulting international staff comprising a venere from a WHO surveys a central venereal ologist a laboratory expert and a public disease clinic and laboratory was established h-alth nurse In addition, lectures and at Addis Ababa in 1952 with the dual clinical demonstrations have been given function of training national staff and of to medical students student nurses health carrying out mass serological tests and Visitors students in public health nursing penicillin treatment WHO has furnished midwives and other medical or para medical a venereologist a serologist and a public personnel health nurse Technicians and auxiliary workers have been trained and will be sent out into the field in secondary teams to Ceylon carry out mass penicillin treatment under In 1951 a venereal disease-control project Chelyah T (1947) C HATA W 13 1 was begun by the health administration of the, T (1949) B N HID HIO 26 Ceylon with WHO providing the services ·central supervision The WHO team also Pakistan helps in work against leprosy Special epidemiological studies in certain In West Pakistan efforts are being made to population groups are being carried out in extend the existing venereal-disease-control Addis Ababa where the laboratory is per facilities in and around Karachi making forming serological tests on selected groups new methods of treatment available to the Serological surveys of 7080 persons have local population of that city and to national been made and variations in seropositivity and foreign merchant seamen A fine of from 82/ among prostitutes in Addis modern clinic centre has recently been Ababa to 23, among schoolchildren have opened which will also be used as a training been found centre for national technical and professional stałT A WHO venereologist serologist and Paraguay public health nurse have been attached to The objective of a campaign in Paraguay this centre which began in 1952 on a limited scale was Among 9 484 patients seen at the Karachi to determine the prevalence of syphilis in the centre between May and December 1953 urban and rural area of Asuncion Villarrica there were 809 cases of syphilis (8 51 where a seropositivity of about 20% had As in all such operations the project is previously been found and to reduce the the responsibilty of the national Govern incidence of syphilis by modern methods of ment which will establish smaller venereal venereal disease control By November 1953 disease-control units in other parts of the 13 200 persons had been examined and 1 822 country These centres will be rud by (14/) had been treated with single doses of persons trained at Karachi It is expected 12 mega units of PAM This pilot project will that these activities will later be expanded serve as the basis for a nationwide attempt and a venereal disease centre is planned for to control venereal diseases Chittagong East Pakistan in 1955 Iran In Iran WHO is assisting the Government Saudi Arabia in the establishment of a modern venereal disease-control and laboratory centre at A venereal disease demonstration has been Teheran and in the expansion and im in operation at Mecca since 1992 with the provement of facilities for venereal-disease assistance of a WHO venereologist and a control in the country as a whole serologist Serological surveys conducted A three months training course for on 10 273 persons have shown a variation medical and ausbary personnel from in seropositivity of from 33 4/ in the armed different provinces started in September 1953 forces to 8/ among schoolchildren and was attunded by 14 doctors 7 laboratory The object of the work has been to set up technicians and 27 physician aids The staff a clinic and a laboratory from which an trained at the centre will assist the Govern investigation into the epidemiology of syphilis ment in the initiation of venereal disease and other venereal infections in different control in other cities and in rural areas of parts of the country may be conducted and the country where technical staff may be trained It has As in other projects of this nature advice been found that syphilis in certain areas of is being given by a WHO venereologist Saudi Arabia is of the endemic type similar serologist and public health nurse to that found in Bosnia Yugoslavia 41 ·the city logical aspects were studied The population of a venereologist and a public health nurse of this oasis is being re examined after six It has been estimated that venereal diseases to eight months This is an example of the affect more than 10% of the total island kind of continuity which WHO seeks to population 2 foster when its direct assistance has ceased A model clinic was established in Colombo to start the control of venereal diseases in Burma Collaboration is maintained with other medical and public health activities A model venereal disease clinic and lab such as maternal and child welfare clinics and oratory has been in operation in Rangoon blood banks Three local subsidiary clinics since 1951 with WHO and UNICEF assist and four outstation clinics run by medical ance The clinic works in co operation with officers trained at the main clinic have been five local venereal disease centres and four set up in different parts of Ceylon Between venereal disease centres in other areas of March 1952 and November 1953 4013 cases the country have been established as part of syphilis were diagnosed among 22 479 of the project There has also been close patients seen at the central and other clinics co operation with maternal and child welfare Special serological surveys have been con centres throughout the country and with a ducted on a total of 46 853 persons who special skin clinic for the treatment of leprosy showed a seropositivity varying from 11 99 Between September 1951 and December among workers in private tanneries to 05/ 1953 a total of 34 571 cases of syphilis were among schoolbovs found among 118 446 patients seen at the Since June 1952 a number of medical main clinic and the outlying clinics including officers have been trained at the clinic and those in Mandalay Moulmein and Pegu courses of lectures have been given to A number of special serological surveys have doctors postgraduate and undergraduate been undertaken in which 39 378 persons medical students sanitary inspectors nurses rural leaders and teachers from the training were tested The seropositivity varied from 25 4% among Rangoon port workers to 24% school among Rangoon students At the Rangoon centre medical officers Ethiopia nurses inspectors laboratory technicians and social workers have been trained by the On the basis of recommendations resulting international staff comprising a venere from a WHO surveys a central venereal ologist a laboratory expert and a public disease clinic and laboratory was established health nurse In addition lectures and at Addis Ababa in 1952 with the dual clinical demonstrations have been given function of training national staff and of to medical students student nurses health carrying out mass serological tests and visitors students in public health nursing penicillin treatment WHO has furnished midwives and other medical or para medical a venereologist a serologist and a public personnel health nurse Technicians and auxiliary workers have been trained and will be sent out into the field in secondary teams to Ceylon carry out mass penicillin treatment under In 1951 a venereal disease-control project was begun by the health administration of Chel at T (1947) Cyfort WA1) 1 the T (1949) B !! HUHI Org 2 $s Ceylon with WHO providing the services 40 ·YABLE VI ENDEMIC SYPHILIS EARLY INFECTIOUS LESIONS AND SEROPOSITIVITY OBSERVED IN FOUR SURVEYS IN MNO SAPNA BOSNIA 1949-52 Ea ly Infectous les ons Seropost ity Mean Popu lat on number of cases of ma populatio umber of cases of mean populat on Ar a survey No $rvey No Survey No Survey No 1 IV 1 11 1 1 5 V 1 Kraljevici 418 30 1 1 2. Ram 1 313 29 7 5 3 356 24 4 16 3 Medjedja Godut 5 Sapna 6. And I 34 495 10 7 0 0 0 72 020 0 0932216 0 06711 08 0 045 03 06 0 0 200 14 0 0260 0 0 0310 010 0 23 13 13 0 O 120 0 0 0 05 0 0 0 A 3 31 1 193 1907 103 57 17 5 3 91. 54 16 212016 97 B 96 326 27 22 70 46 141 3 19 8 13.04008 es 6 24 10 17283 4820 78 6 5 3 286 95 1811 181 1961 800404 31 7 2 176 101 2.307 97 57 15 12 23 3 137 3629 23 12 3 0 118 62 1.5 0 273 7 7 Mahmutov 11 225 7 0 74 & Ko acevic 307 4 9 M Nezuk 416 5 O 0 10 JUS 195 1 0 0 Total 3,352 136 17 22 0 410507 0 896478 197 41 26 7140 57 14 Mo 18 a sm I admi Istrati e nit. The total a ea of Mno Spa is 125 sq a klomet es (48 sq a em les) 94.5 of the mean total popul to was examined The four survey were carried out on the followi g dates J 2 October 1949 II 4 Ap II 1950 30 June 1951 JY 10 Jan ary 1952 D I each 8 rvey the cases found were t eat din survey 11 household contacts were also t eated the entire population was examined at the first survey and when treatment was given to all household and family contacts The abortive treatment of such contacts consisted of single snjections of 12 mega units of PAM The gradual decline in the numbers of early infectious cases and in seropositivity is well illustrated in table VI and fig 18 The valuable experience gained in this programme has been described by its director DI E I Guin who points out The reservoir as a whole has been brought under control, and the attitude of the people to the problem has been altered this is due partly to some general improvement in the social and economic conditions partly to the work of the field teams and to the general progress of the campaign and partly to the fact that new cases of endemic syphilis are now detected more rapidly and can be more quickly dealt with "The epidemiological situation cannot conceivably return to its original form after one or two follow up examinations have been made but constant super vision of previously endemic areas is necessary as part of the long term programme In Bosna such supervision and health control are provided by one or more health workers remaining in the field between control examinations and after the field campaign proper has come to an end. Being selected from the field teams they are familiar with endemic syphilis as a rural health problem in all its aspects The health workers co-operate with the local health centres which assume the responsibility for keeplog the disease under control through their pormal machinery against communicable diseases in the consolidation phase of the long term programme The present programme is serving as a bridgehead to the development of general public health services and to the expansion of the machinery against com municable diseases Gn E.1 (1953) Epidemi lynd Indemi ypk fis port Mars-1 ampaig Boia, G DEV (# Hali Oganizati Monog pHSIN II PP 75 76 43 ·Taiwan assess the extent of the problem in Taiwan A demonstration project was initiated in for example a serological survey of 1 660 Taiwan in 1953 with WHO and UNICEF terchers is at present in progress The assistance This project seeks to provide existing laboratory services will be strength venereal disease control services for all preg ened and laboratory techniques standard nant women and for children and ultimate ized Local staff is being trained by a team ly to establish an islandwide venereal of national and international advisers and disease control programme including health education is being emphasized The special port demonstration main demonstration centre is at the pro Surveys will be carried out in order to vincial hospital in Taipeh a ENDEMIC SYPHILIS IN BOSNIA There is historical evidence that syphilis were examined in all more than a million was introduced into Bosnia by the Ottoman examinations and re examinations were made armies in the 18th century By the end of the By the end of 1952 35 238 persons 81% of 19th century the disease was already wide the examined population had been treated spread both in Bosnia and in Herzegovina with penicillin Owing to unhygienic living conditions low The campaign directed from a central educational and economic standards and headquarters in Sarajevo was carried out by certain social customs such as the common three field groups each composed of several use of drinking vessels the disease became teams in co operation with the local health endemic officers of the districts being covered During Investigations undertaken in Bosnia during the early days of the campaign infectious cases were treated with PAM adults receiving the years 1905 11 jadicated a prevalence of a total of 36 42 mega units 83% and a study carried out between 1926 in Six or seven injections given daily or every other and 1933 gave a figure of 11 8%. Before 1948 attempts to control endemic syphilis with day Later the total dosage was given in a In single injection and no difference was neoarsphenamines were unsuccessful observed in the results that year the Yugoslav health administration Finally single injections of 1 8 mega units were used in a initiated a nationwide syphilis control pro number of areas gramme paying special attention to endemic Although at the beginning it was felt that syphilis in Bosnia and requested the assist ance of WHO and UNICEF The approach the greatest danger to the success of the to the problem was governed by the realiza campaign was the risk of relapses it soon tion that if the campaign against endemic became apparent that this was negligible in syphilis was to succeed fully it must accom comparison to the reinfections that occurred pany measures to improve the standards of and the reactivation of endemic foci from education and health in general cases that were missed absent or in the In this campaign a systematic serological incubation period at the time of the first survey The need for resurycys in which the screening was undertaken in which approx entire population was again examined became imately 435 000 persons or 95% of the total endent The best results were obtained when census population of the endemic areas 42

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·FIG 18 DECREASING PERCENTAGL OF SEROREACTORS FOLIOWING MASS TREATMENT CAMPAIGN AGAINST ENDEMIC SYPHILIS IN BOSNIA KOVAČEVICI GODU] MARXUTÓNIC) Une SAPNA ANDJELI" KRALJEVICI NREUX First survey October 1949 KOVACEVICI RANICE copus MAHMUTOVICI JUSIČI ED) DA SAPNA ANDJELICI Realleries * NEZUR Second Surrey April 1997 Seroreactor 396 B 04-101 118-193 m 23.3 296 311-329 . See 3.30! XP 13

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·These are satisfactory conclusions and (c) that a treponematosis project can they indicate serve as a bridgehead for future public health (a) that a treponematosis can be brought activity under control by means of mass treatment It is believed that the campaign in Bosnia with penıcıllın if suitably applied not only is to the considerable credit of the (b) that a programme to combat endemic local health administration but also has been syphilis itself stimulates social advancement one in which most useful experience has been which in turn renders the environment gained for application in the management of unsympathetic to the return of the disease other mass campaigns of which it has been and in its way the prototype BEJEL AND DICHUCHWA Bejel in Iraq Ramadı region north of Baghdad was first selected for study later surveys were In Iraq treponematosis-control activities are centred on bejel the syphilis like disease undertaken in the Mosul region in the north described by Hudson 5 in 1928 A joint the Amara region in the south and subse quently in other areas It became apparent WHO/UNICEF aided demonstration in bejel that the disease was not so widespread as had control was initiated in 1950 An area in the first been feared and that it occurred most Hudson E.H (1928) Na med Bull Hash) 26 817 frequently in the river bed areas and particu FIG 19 PERCENTAGE DISTRIBUTION OF CLINICAL SYMPTOMS AND SEROPOSITIVITY IN BEJEL 1100 20 80 60 20 0 Lam A Cross section of 3,507 cases of untreated bezel of total patients with particular symptom (scale on left chnical symptoms) D / seroreactors (scale on right seroreactors) 46 ·FIG 21 LATE BEJEL larly among the marsh Arabs of Amara where the difficulties of transport were greatest and the people therefore most isolated The areas where bejel is prevalent have been the site of a mass campaign of treatment with penicillin By the end of December 1953 more than 134 000 persons had been exam ined and more than 78 000 cases and contacts treated Progress in this campaign has been less rapid than in similar WHO/UNICEF assisted projects partly because the popula tion is widely scattered and because the mas FIG 20 EARLY BEJEL In late stages of the treponematoses there may be painful osteopeniostinis as illustrated above in a case of bejel (GC ke, Lond) facilities for communication and transporta tion in the areas of high prevalence are limited As has been indicated on page 16 there is great simularity in the epidemiology and in clinical manifestations of bejel and endemic syphilis The late lesions are comparable to the gummata osteoperrostitis and nasal laryngeal and palatal lesions of benign tertiary syphilis A cross section of 3 507 cases of untreated bejel confirms this view 6 and is illustrated in fig 19 Bejel lesions observed in Iraq are shown in fig 20 and 21 Other examples including one of extreme mutilation have been de scribed by Jones? Csonka, G (1953) BIJ Dos 29 95 Jes LG (1933) Bt Du 29 104 General paprlar eruption in woman three weeks pregnant This patient was treated with 12 mega units of PAM and at term delivered a healthy seronegar e child ( GC nk lod) 47 ·These are satisfactory conclusions and (c) that a treponematosis project can they indicate serve as a bridgehead for future public health (a) that a treponematosis can be brought activity under control by means of mass treatment It is believed that the campaign in Bosnia with penicıllın if suitably applied not only is to the considerable credit of the (b) that a programme to combat endemic local health administration, but also has been syphilis itself stimulates social advancement one in which most useful experience has been which in turn renders the environment gained for application in the management of unsympathetic to the return of the disease other mass campaigns of which it has been and in its way the prototype BEJEL AND DICHUCHWA Bejel in Iraq Ramadı region north of Baghdad was first selected for study later In Iraq treponematosis control activities surveys were are centred on bejel the syphilis like disease undertaken in the Mosul region in the north described by Hudson 6 in 1928 the Amara region in the south and subse It became apparent WHO/UNICEF arded demonstration in bejel quently in other areas control was initiated in 1950 An area in the that the disease was not so widespread as had first been feared and that it occurred most Hudson, E H (19.8) N md Bull (Hash ) 26 817 frequently in the river bed areas and particu PERCENTAGE DISTRIBUTION OF CLINICAL SYMPTOMS AND SEROPOSITIVITY IN BEJEL A joint FIG 19 100 20 80 19 60 10 20 0 & ont $ ܪܫܟܣ . Cross section of 3,507 cases of untreated bejel of total patients utih parniculur symptom (scale on left clinical symptoms) D / seroreactors (scale on righr seroreactors) 46 ·MASS CAMPAIGNS AGAINST YAWS Halti medical staff is limited mass treatment has been carried out by rapidly trained auuliary of 3 5 million people living in the Repub- personnel and local inspectors who are also lic of Haiti approximately five out of six qualified chauffeur mechanics have performed live in underdeveloped rural areas where the bulk of the work These 4 injectors yaws has for some time been rampant have given treatment to everybody regard Although it is difficult to estimate the pre less of age or clinical or anamnestic evidence valence of the disease in the past it is thought of yaws Satisfactory results have been that approximately 15 million people had obtained by giving 600 000 units of PAM to yaws a few years ago yaws cases those without clinical manifesta In 1941 on the request of the Government tions or history of the disease have received of Hait to the Pan American Sanitary only 300 000 units and children and infants Bureau a yaws survey was made and plans have been given proportionately smaller put forward for the control of the disease doses Early in 1942 a limited programme based on By the autumn of 1951 666 738 persons treatment at stationary clinics was started had been treated in clinics When the first jointly by the Government of Haiti and the census figures became available however Institute of Inter American Affairs At it was found that an insufficient percentage first metal chemotherapy was used but later of the population was being reached and penicillin was substituted after a demonstra a change was made to a house to house tion of the excellent effects of penicillin in oil method of treatment in which each person and beeswax 8 seen was given an injection of penicillin in In 1948 the United Nations Mission of the same doses as before With this method Technical Assistance to the Republic of 1 700 240 persons (about 97% of the popula Haiti recommended that an organized nation tion of the new areas covered) were treated wide mass campaign with penıcıllın be under between October 1951 and September 1953 taken This proposal was considered by the Sample surveys carried out in these areas WHO Expert Committee on Venereal Infec eight months after treatment showed that tions in 1949 which recommended that in the initial knock down had been satis the Republic of Haiti and the Dominican factory very few cases of infectious yaws Republic an epidemiological experiment be were found On the other hand in the areas carried out with simple nass technique that relied on the fixed clinic system and and using procaine penicillin in oil with where substandard penicillin had been used aluminium monostearate (PAM) in some cases isolated foci of infection The present campaign began in July 1950 persisted and some of them had already with a team of WHO technical advisers and begun to expand It has therefore become UNICEF supplies and has been in continu necessary to revisit each house in these areas ous operation since that time The simplest treating all persons regardless of presence methods have been used throughout As or absence of the disease with a satisfactory penicillin Dwell H Sb II LAJ RI,CR & Sterberg TH. There is a substantial focus of venereal (1947) Amer Md 21 633 #WHILO WRPS 1950 13 16 syphilis in the urban area in and around 49 ·FIG 22 EFFECTIVENESS OF PENICILLIN IN BEJEL Even in far-advanced late cases of bejel the infection may be arrested by a single injection of long-acting penicillin as shown in the above photographs Left before treatment nght three weeks after one injection of 24 mega units of PAV (LGO Jones Lo do ) been selected for the preliminary investiga Dichuchwa in Bechuanaland tions control and follow up measures are It has already been mentioned that being undertaken on a family basis Treat dichuchwa a treponematosis similar to or ment is being given to all active cases of identical with endemic syphilis and bejel is treponemal diseases to all latent cases (as encountered in some parts of Africa A joint determined by anamnesis) and to the con WHO/UNICEF programme to control this tacts of infectious cases Contacts have been infection was initiated in Bechuanaland in defined as all adults in the same house and November 1953 all children under the age of 16 years in the Field operations during the first year of the same kraal as any infectious case In November and December 1953 5 000 project are being limited to a study of the and serological persons were examined Information obtained thus far will form the basis for a aspects of the infection including the response The m255 treatment campaign which will begin to treatment of cases and contacts with UNICEF assistance towards the end Bakwena Reserve which is occupied by the of 1954 40 000 members of the Bakwena tribe has epidemiological clinical 48 ·A WHO/UNICEF assisted campaign began prevalence is 36/ and reaches 30% in certain in April 1950 The campaign is being carried areas The disease is most common on the out by mobile teams composed of one smaller islands along the sea coast along medical officer and usually four auxiliary rivers and in the swampy regions of the workers 17 regular teams and three follow up larger islands teams are at present at work A WHO team The Philippine Government assisted by of advisers is assisting the national health WHO and UNICEF began a yaws-control administration campaign in April 1951 in the nine provinces Until the end of October 1952 the treat with the highest prevalence The campaign ment consisted of two injections of 1 2 mega was started in the island provinces of units of PAM each Since that time single Samar and Leyte where the prevalence was injections of 1218 mega units of PAM believed to be about 8/ among the rural have been given The Government has population There are altogether six mobile supplied one third of the penicillin and teams which travel from village to village UNICEF two thirds the population is told in advance when the Where the prevalence of yaws is 15% or team will arrive and a census is taken over or where there is a high proportion Local sanitary inspectors and other health of infectious cases the treatment of contacts personnel work with the team and are given has been extended to include not only house training in yaws control As the teams move hold contacts but also all contacts in the on the records are left behind in the charge same class at school as children found to of the president of the sanitary division who have infectious yaws Resurveys are being arranges for the follow up of those treated undertaken in the treated areas In this manner the campaign becomes In the three and a half years up to integrated into the public health structure of November 1953 a total of 2 581 879 persons the province had been examined (first examination) Treatment was originally given by injec 317 892 had been treated for the first time tions of 0 6 mega units of PAM for children and 6 391 re treated About 34 093 of the under ten years of age and two injections treated cases were discovered at resurvey of 12 mega units each for adults These It was planned that about 750 000 people doses were changed to accord with recom were to be examined in the second half of mendations made at the First International 1953 and 1 750 000 in 1954 At the present Symposium on Yaws Control which was rate of progress the work will continue for held in Bangkok in 1952 A single injection the next three to five years Approximatel procedure is now being used Up to Decem 54% of the cost is borne by the Government ber 1953 1 880 867 persons had been exam and 46/ by UNICEF ined and 71 783 treated with penicillin Resurveys of the control areas and of all Philippines areas in which the prevalence exceeded 10/ have been carried out by two teams The The Philippine archipelago consists of results of one resurvey showed a prevalence 7021 islands with a total population of about of 2 48/ in a population of 16 000 persons 20 million of whom three quarters live in as compared with 18/ at the first survey rural areas Yaws is reported to be endemic India in 39 of the 51 provinces in 30 of these the prevalence is reported to be less than There are pockets of yaws in India in parts 1/ but in the remaining nine the average of the Madhya Pradesh and adjoining States ·Port au Prince and measures against it to report to a site where the diagnosis is before the Haiti programme is completed checked and treatment administered are being considered The campaign as a whole is run from Haiti is only one part of an island shared headquarters at Jogjakarta from which by the Dominican Republic It is clear several important pilot studies have been therefore that the eradication of yaws will carried out to determine the efficacy of be difficult unless control efforts are under various treatment schedules and methods of taken in the border areas of the Dominican approach to the communities A study is Republic as well and steps to this end are also being made of the efficacy of diamine under consideration penicillin under tropical conditions At the beginning of the campaign adults were treated with two injections of 1 2 mega Indonesia units of PAM each given at intervals of from four to seven days smaller doses were given The population of Indonesia is estimated to children Recently single injections of at 75 million the vast majority living in 1 8 mega units have been given It is now rural areas It has been stated that there accepted in principle that the treatment of are about 10 million cases of yżws in the apparently non infected house and school country contacts with half this dosage is necessary Active yaws work was carried out with To date however comparatively few con arsenicals in Indonesia before the Second tacts have been treated World War but during the war control In all a total of 6 745 515 persons had measures were discontinued and a sharp rise been examined and 1 079 224 treated up to in the incidence of the disease took place the end of 1953 No fewer than 73 205 per Plans for the control of yaws with the help sons were treated for the first time during of WHO and UNICEF were drawn up by resurveys indicating the necessity of re the Indonesian Government and WHO examining the total population on these consultants and the work began in May occasions The populations covered have 1950 Starting with two areas in the residen frequently reached the desired level of 90% cies of Jakarta and Jogjakarta the operations have since been extended to west Java Balı and Flores north Sumatra and South and Thailand West Kalimantan (Borneo) The campaign is based on teams of six of the 18 3 million people in Thailand it or eight trained nurses working under the is estimated that approximately 60/ or about 11 million live in areas where yaws supervision of full time and part time medical is found Officers Oning to the shortage of personnel From surveys of these areas it is estimated that there may be about 1 430 000 a scheme has been introduced by which cases of yaws The distribution of the disease 200 assistant nurses working in dispensaries IS patchy but here as elsewhere it under the supervision of the trained nurses associated with remoteness filth and low are being instructed in the diagnosis and standards of personal hygiene Previously treatment of yaws Early in 1953 there were 24 regular mass treatment teams and 35 arsenicals were administered at a few station These teams ary rural clinics but as in other parts of simplified teams in the field the world they had little or no effect in eramine the entire populations of villages controlling the disease and all patients with actre yaws are asked 1$

·Gross gangosa (rhinopha yngitis munilars)
(C I Hack tt Lod)
Carrara
of
Generali ed mulriple papillomata
(F N Gwmarãe Rio d Jan v>
+
Incapacitaning planta hyper keraſoftc lesions
FNG marãe Rd deu)
+
17

·FIG 23
LESIONS OF YAWS
Indolent ulceration of the elbow
(C J Hack tt Lond n)
Bone deformation lit tertiary jans
(E E. Kruin i Rijk Netherland)
Juxta-crticular noduks In patellar region
CI Hkkett, London)

·national Refugee Organization (IRO) and actions) were often considered ineligible as WHO immigrants However new and effective Refugees still present a problem in many methods of treatment with penicillin and thparts of the world More than 850 000 Arabs realization that a positive serological test have been living for some years in camps in does not always mean active syphilis in Lebanon Syri3 the Hashemite Kingdom of adequately treated persons with a negative the Jordan and the Gaza area of Israel As spinal fluid have led several nations to change part of the international and which they their regulations This change fostered 10 recere considerable attention is paid to the part by WHO has brought hope to thousands improvement of maternal and child health of persons in desperate situations who were and to the control of communicable diseases hitherto automatically precluded from em including syphilis gration to new countries A serological survey carried out in 1950-51 among 8 259 pregnant women in Lebanon Syria and Gaza showed that 53/ of them Seafarers were serologically positive for syphilis WHO arranged for these women to be treated with The historical importance of seafarers 10 penicillin and undertook the necessary the dissemination of syphilis has been appre measures for the general control of syphilis ciated since the time of the classical epidemic At the same time the Organization took of syphilis which spread through Europe steps to ensure that the laboratory procedures after the return of Columbus from the New used in the diagnosis of cases were of the World The development of the steamship highest standard 12 the 19th century and the realization of its Other refugees-for example those dis potential in the 20th century gave rise to much placed by the partition of India and lodged concern about the spread of venereal diseases In camps in Pakistan--have been assisted by seafarers This resulted in the Brussels through demonstration centres established Agreement of 1924 which provided for free with international assistance treatment in the major ports for seafarers suffering from venereal infections Fifty seven countries and their overseas territories Migrants have adhered to this Agreement which was Consultations have taken place between established on the initiative of the Red Cross the International Labour Organisation (ILO) the International Union against Venereal IRO and WHO on the medical requirements Diseases and the International Labour Orga of various countries which have been or are nisation WHO took over the administration accepting immigrants and on the require of the Agreement from the Office Interna ments as to persons who have been treated for tional d Hygiène Publique in 1948 syphilis Countries that accept immigrant Because of the striking changes in the labour have different medical requirements nature and extent of the treatment of syphilis and it is desirable to ensure that persons and other venereal infections WHO on the emigrating from one country to another are recommendation of the First Health Assem not turned back on arrival because of those bly 19 assumed the responsibility for study differences ing the possibility of revising the Brussels In the days before penicillin persons with Agreement with a view to establtsbing WHO positive serological tests for syphilis (exclud ing those with biological false positive te OF R WIL HERO 1948 13 303 ·An active campaign undertaken by the State for survey training and mass treatment is Government of Madhya Pradesh in the years now under way conducted with international 1941-45 was successful in reducing the inci assistance by one mobile team Since April dence of the disease but financial stringency 1953 97 212 persons have been examined brought it to an end and the incidence has and 5 821 persons including 829 contacts since increased treated with penicillin A campaign to stamp out yaws from this area has now begun with WHO and Liberia UNICEF assistance It started as a pilot In Liberia where the population is about project in the Madhya Pradesh and was 15 million malaria and yaws are the main extended to the State of Hyderabad in public health problems It is estimated that July 1953 it is proposed to extend it later to approximately 30% of the population are the other adjoining States Up to November afflicted with yaws Even in the capital 1953 85% of the total population of 79 813 Monrovia there is a reported prevalence of persons in 556 villages had been examined 16% to 199 789 cases of yaws (56%) had been found With international assistance a survey of a and persons with lesions or a history of yaws population of 50 000 was begun in March and contacts of infectious cases had been 1953 in the vicinity of Ganta where malaria treated is also very prevalent A house to-house survey of the Kpaing area began in August 1953 and resurveys will take place at intervals Laos of six months These surveys will be com The population of Laos is estimated at bined with antimalaria activities All clinical 15 million in the four southern provinces cases found will be treated with penicillin with a population of 610 000 the estimated and contacts will receive preventive doses prevalence of yaws in some areas is between In the Bahn area field surveys have so far 10% and 15% Conditions of security and been undertaken in 16 villages where 4918 communications allow approximately 60/ persons have been examined of whom 63 9/ of the population in the south to be reached were found to have yaws by jeep but only in the dry season Up to December 1953 14 846 persons had Previously yaws cases were treated with been examined and 10 840 trezted (including arsenicals at stationary clinics but a project contacts) in this project vast groups in SYPHILIS CONTROL IN SPECIAL POPULATION-GROUPS Certain population groups require con The need for controlling yenereal diseases sideration as units although their individual particularly syphilis in members may come from many countries Europe and Asta was recognized at the time and the importance of reducing Among such groups are refugees migrants congenital syphilis was included in the plans and seafarers for the maternal and child health activities of Refugees the international organizations this end was undertaken in Europe first by The problem of refugees was at its height UNRRA and later by the former Inter immediately after the Second World War Work to ·risen by 10% since 1946 and is now diseases is likely to hold the interest of according to the Lloyds Register for 1952 maritime nations throughout the world and a total of 90 868 495 gross tons In the light health administrations may wish further of this steady increase in tonnage and in international action with regard to this truly floating population the problem of venereal jotemational problem INTERNATIONAL EXCHANGE OF TECHNICAL INFORMATION The exchange of technical information is important purpose experience has demon of immense value to countries and its pro strated that methods of combating a disease motion and execution are therefore a basic that may be efficient and effective in one coun function of WHO In effect the Organization try may have little practical value as long as acts as an international clearing hou for they are not sted and accepted by other this purpose It is essential that the latest countries with similar problems It is there information on progress in the prevention fore essential when drawing up overall plans diagnosis treatment and other aspects of for control of a disease to have the benefit of treponematosis control be made available cxpert views representative at the same time to all interested countries 50 that control of various technical aspects and of national activities may be in step with the march of methods of control it is principally for this events Much information is always obtain purpose that WHO has established a series able from current medical literature but the of expert advisory panels each concerned programmes of health administrations and with specific problems of WHO yield important data which can best Technical guidance in WHO s treponema be made known through the Organization toses activities is provided by an Expert In addition as a result of its operational Advisory Panel on Venereal Infections and studies and as a co-ordinator of international Treponematoses the members of which are research WHO is an important source of appointed by the Director General because knowledge on specific subjects of wide of their competence in this particular branch interest of medicine and by expert committees the members of which are drawn from the panel Expert Committees and Advisory Panels and the composition of which varies accord ing to the subject chosen for consideration In recommending technical policies as well at a particular committee session At the as in advising governments on measures present time WHO has an erpert advisory concerning treponematosis control WHO panel of 73 members from 44 countries upon must be able to call upon the technical advice whose technical knowledge and experience of persons who are not only most competent in the treponematoses it may draw in their field but also representative of the Four expert committee meetings have been newest trends and of as wide a geographical held-two in 1948 and one each 10 1949 distribution as possible This last considera and 1952 A Subcommittee on Serology and tion is in line with the international character Laboratory Aspects has also held three of the Organization it also serves another sessions-In 1949 1950 and 1953 The tech ·health regulations in this field similar in prin WHO was instrumental through its ciple to those for quarantinable or pestilential headquarters and its Regional Office for diseases No definite steps were taken until Europe in the establishment of the Inter the pattern of the new international regula national Anti Venereal Disease Commission tions with regard to other diseases should of the Rhine an intergovernmental body become clear with the coming into force of on which were represented the five countries the International Sanitary Regulations in sharing the Rhine River system 1952 In the meantime on the suggestion of Finally WHO sometimes assists govern the International Union against Venereal ments directly in the establishment of port Diseases the Netherlands Government estab treatment facilities for venereal infections fished the Rotterdam Port Demonstration eg in Karachi Pakistan Centre with the assistance of WHO Among The technical interest of WHO in maritime the activities of the Centre is the study of venereal disease control has been in fostering certain aspects of marıtıme venereal disease standardized methods of diagnosis and the control and of the functioning of the Brussels rapy among seafarers so as to obtain more Agreement uniform treatment schedules and serological The control of venereal disease among sea tests at ports in different countries Although farers and the place of venereal infections in wide variations still exist the introduction maritime public health in general were also of penicillin therapy in syphilis has greatly considered by the Joint ILO/WHO Com simplified the previously complicated situa mittee on the Hygiene of Seafarers in 1949 11 tion resulting from the need to retain sea and will be studied again when this committee farers for prolonged treatment ashore with meets in April 1954 It is expected that the metal chemotherapy The ficts that penicillin legal aspects of the Brussels Agreement will treatment of early syphilis requires only a be considered by WHO in 1955 and that a few sessions and that the patient need not be study of the proposed WHO health regula hospitalized have substantially reduced ab tions will subsequently be transmitted to senteeism and the number of man days lost in governments and to the interested interna home and foreign ports which is an economic tional organizations gain for the employer and employee alıke and for the government concerned But WHO has published a revised edition of new problems have arisen because of the the International list of renereal discase comparative case with which crews have treatment centres at ports which gives vener access on board ship to penicillin given eal disease clinics in the major ports through parenterally or orally for therapeutic and out the world and the hours of attendance prophylactic purposes this has made post A further edition is due in 1955 Similarly treatment control and follow up more com the individual treatment record booklet issued plicated under the Brussels Agreement has been The problem of immediate importance in revised and brought up to date maritime venereal disease control is early In its role as administrator of the Agree syphilis In some maritime countries the ment WHO receives complaints from health incidence of early syphilis has been less administrations about services in ports and noticeable in port than in inland areas but acts as intermediary between the govern on the other hand increasingly important ments concerned The exchange of epidemi ports in underdescloped areas remain very ological information is also encouraged real foci of infection at a time when the tonnage of post war merchant fleets has H11 HIM OR SR 195 20 ·risen by 10/ since 1946 and is now diseases is likely to hold the interest of according to the Lloyds Register for 1952 maritime nations throughout the world and a total of 90 868 495 gross tons In the light health administrations may wish further of this steady increase in tonnage and in international action with regard to this truly floating population the problem of venereal international problem INTERNATIONAL EXCHANGE OF TECHNICAL INFORMATION The exchange of technical information is important purpose experience has demon of immense value to countries and its pro strated that methods of combating a disease motion and execution are therefore a basic that may be efficient and effective in one coun function of WHO In effect the Organization try may have little practical value as long as acts as an international clearing house for they are not tested and accepted by other this purpose It is essential that the latest countries with similar problems It is there information on progress in the prevention fore essential when drawing up overall plans diagnosis treatment and other aspects of for control of a disease to have the benefit of treponematosis control be made available expert views representative at the same time to all interested countries so that control of various technical aspects and of national activities may be in step with the march of methods of control It is principally for this events Much information is always obtain purpose that WHO has established a series able from current medical literature but the of expert advisory panels each concerned programmes of health administrations and with specific problems of WHO yield important data which can best Technical guidance in WHO s treponema be made known through the Organization toses activities is provided by an Expert In addition as a result of its operational Advisory Panel on Venereal Infections and studies and as a co ordinator of international Treponematoses the members of which are research WHO is an important source of appointed by the Director General because knowledge on specific subjects of wide of their competence in this particular branch interest. of medicine and by expert committees the members of which are drawn from the panel and the composition of which varies accord Expert Committees and Adnsory Panels ing to the subject chosen for consideration In recommending technical policies as well at a particular committee session At the as in advising governments on measures present time WHO has an expert advisory concerning treponematosis control WHO panel of 73 members from 44 countries upon must be able to call upon the technical advice whose technical knowledge and experience of persons who are not only most competent in the treponematoses it may draw in their field but also representative of the Four expert committee meetings have been newest trends and of as wide a geographical held-two in 1948 and one each in 1949 distribution as possible This last considera and 1952 A Subcommittee on Serology and tion is in line with the international character Laboratory Aspects has also held three of the Organization it also serves another sessions-in 1949 1950 and 1953 The tech ·health regulations in this field similar in prin WHO was instrumental through its ciple to those for quarantinable or pestilential headquarters and its Regional Office for diseases No definite steps were taken until Europe in the establishment of the Inter the pattern of the new international regula national Anti Venereal Disease Commission tions with regard to other diseases should of the Rhine an intergovernmental body become clear with the coming into force of on which were represented the five countries the International Sanitary Regulations in sharing the Rhine River system 1952 In the meantime on the suggestion of Finally WHO sometimes assists govern the International Union against Venereal ments directly in the establishment of port Diseases the Netherlands Government estab treatment facilities for venereal infections lished the Rotterdam Port Demonstration eg in Karachi Pakistan Centre with the assistance of WHO Among The technical interest of WHO in maritime the activities of the Centre is the study of venereal disease control has been in fostering certain aspects of maritime venereal disease standardized methods of diagnosis and the control and of the functioning of the Brussels rapy among seafarers so as to obtain more Agreement uniform treatment schedules and serological The control of venereal disease among sea tests at ports in different countries Although farers and the place of venereal infections in wide variations still exist the introduction maritime public health in general were also of penicillin therapy in syphilis has greatly considered by the Joint ILO/WHO Com simplified the previously complicated situa mittee on the Hygiene of Seafarers in 1949 11 tion resulting from the need to retain sea and will be studied again when this committee farers for prolonged treatment ashore with meets in April 1954 It is expected that the metal chemotherapy The facts that penicillin legal aspects of the Brussels Agreement will treatment of early syphilis requires only a be considered by WHO in 1955 and that a few sessions and that the patient need not be study of the proposed WHO health regula hospitalized have substantially reduced ab tions will subsequently be transmitted to senteeism and the number of man days lost in governments and to the interested interna home and foreign ports which is an economic tional organizations gain for the employer and employee alike and for the government concerned But WHO has published a revised edition of new problems have arisen because of the the International list of venereal disease comparative ease with which crews have treatment centres at ports which gives vener access on board ship to penicillın given cal disease clinics in the major ports through parenterally or orally for therapeutic and out the world and the hours of attendance prophylactic purposes this has made post A further edition is due in 1955 Similarly treatment control and follow up more com the individual treatment record booklet issued plicated under the Brussels Agreement has been The problem of immediate importance in revised and brought up to date maritime venereal discase control is early In its role as administrator of the Agree syphilis In some maritime countries the ment WHO recerses complaints from health incidence of early syphilis has been less administrations about services in ports and noticeable in port than in inland areas but acts as intermediary between the govern on the other hand increasingly important ments concerned The exchange of epidemi ports in underdexcloped areas remain very ological information is also encouraged real foci of infection at a time when the tonnage of post war merchant fleets has W14 HUR Org te let S 1990, 20

·FIG 24
ACTIVITIES OF WHO TREPONEMATOSES CONSULTANTS AND ADVISERS 1948 53
po
59

·in Paris 13 nical reports of these groups hare furnished Study Commission to the USA in which a the basis for WHO work against the trepone group of specialists from seven countries matoses they are also a valuable source of spent several months of 1949 in the USA up-to date techncal information for phy to investigate and evaluate the use of peni sicians public health authorities and others cillin in the syphilis-control programme of interested in treponematoses control the USA as organized by the US Public Health Service The Commission also observed other aspects of the programme in Symposia and Other Conferences the USA among them the technique of WHO fosters exchange of technical inform contact interviewing and the training of ation by sponsoring symposia and other contact interviewers the morbidity and epi international conferences Such meetings demiological report forms and the mechanical bring together leading specialists from differ methods used in their filing and analysis ent countries and make possible direct and the inpatient facilities provided by rapid professional contact and exchange of views treatment centres and the education of the For example an international symposium on patients carried out therein syphilis was organized in Helsinki in 1950 1 The Commission concluded that the and was attended by 28 participants from venereal disease control methods used in the SIX countries in the same year a larger USA could well serve as a guide in planning symposium at which participants numbered future programmes elsewhere provided that 76 and represented 12 countries was held they were suitably adapted to local con These symposia did much to ditions and requirements that the value of reorient European medical opinion with penicillin in the treatment of syphilis was an regard to the new trends in the treatment of outstanding USA discovery and that the syphilis and to hasten the transition from USA was at that time the place of choice metal chemotherapy to therapy based on for the study of venereal disease problems penicillin and control methods The results of the In 1952 an international symposium on Commission s study were published in the yaws control was held in Bangkok and was WHO Technical Report Series 15 attended by 39 participants from 23 countries This symposium covered every phase of yaws Consultant Aid control and provided an important forum for the exchange of experiences in the large Another more direct method of exchang yaws control projects getting under way in ing technical information is seen when the several parts of the world The technical Organization provides an expert adviser or information which was presented at the consultant for a national health administra symposium was subsequently published in a tion Such technical personnel may be mem WHO monograph " bers of the staff of WHO headquarters or of An earlier and different type of activity the regional offices or may be experts re was that represented by the WHO Syphilis cruited for assignment to a specific project for a shorter or longer period The provision Tan nion Scho 1 national Symp ww on the Study * (Socks ) Suprl of etpert advice in this way has been found Srưu (1931) H = 4 a most useful type of WHO assistance both Organisation Mndiale de 1 Sa té (1951) C lyuli in demonstration and training projects and World Healb OTT tron (1953) Tu I termasual Symbo! You Cont of Geneva (How It alth Organl. HZHI Org I h R$ 1950 15 drm frem ) mal star La Srpd Pas 10 11 wrap Ses No 13 ·strengthening the health services of nations tions publications-the Technical Report and for bringing participants to symposia Series the Monograph Series and the and international conferences in which WHO Bulletin of the Horld Health Organization has had an interest The reports of the WHO Expert Committee A number of special training courses have on Venereal Infections and Treponematoses been organized with the assistance of WHO and of its Subcommittee on Serology and In Sımla Himachal Pradesh India teans Laboratory Aspects and the collective views composed of a venereologist a laboratory of other groups of experts such as the WHO technician and a public health nurse-from Syphilis Study Commission to the USA different parts of the country were trained as will be found in the Technical Report Series groups in venereal disease-control methods A Extensive studies which are considered to field seminar organized in connexion with the have lasting value and which are of wide gene international yaws symposium in Bangkok ral interest but which do not present a col was another type of group training A third lective view of a problem are included in the example is the group-training courses in Monograph Series This series contains either maritime venereal disease control at the port epidemiological or clinical studies on one demonstration project in Rotterdam specific subject by one individual author- WHO has also awarded a limited number such as the monograph The epidemiology and of grants to universities and laboratories control of endemic syphilis report on a mass in support of work which has a direct bearing treatment campaign in Bosma-or a collection on the activities of health administrations of papers by a number of contributors on a and on WHO programmes For example certain topic—such as the selection of papers grants have been made to the WHO Ser submitted at the First International Sym ological Reference Laboratory at the Statens posium on Yaws Control Finally the Seruminsutut Copenhagen and to the Bulletin contains in each volume a number of International Treponematosis Laboratory scientific papers prepared either by epidem Center at Johns Hopkins University Balti ologists clinicians or public health workers more Md USA The activities of these who carry out assignments directly under the centres are reviewed in a later section auspices of the Organization or by outside (pages 63 and 66) It should be mentioned contributors who wish to give their original here however that these laboratories also findings a wide international distribution serve to train laboratory workers and tech Information included by WHO in any of nicians sent to them either by WHO or by these publications has always to meet certain other interested national and international special requirements First and most specific organizations of these is that it should have international significance It is one of the principles of Technical Documentation the WHO publications programme that a paper should not be included in an Organiza One of the principal means of disseminating tion publication if a more suitable vehicle information is represented by WHO publica for it exists Although the expression tions and technical documents through international significance 18 not easily which the Organization makes available defined it is meant in general to distinguish the information resulting from its own work information which in contradistinction to Trepanematologists and public health that of a purely local of national interest is workers will find information of interest to likely to be of practical value to health them particularly in three of the Organiza workers in a number of countries or to 61 ·in mass campaigns The countries which In some instances the training has been requested and received the services of WHO in general public health methods in others consultants and advisers during the period Fellows have studied syphilis control in 1948 53 are shown in fig 24 clinics or at the city provincial, or national level in others again laboratory aspects or Fellowshops and Other Professional Training subjects of study Many of the fellowships mass campaign practices have been the Activities have been granted in cooperation with The awarding of fellowships and travel UNICEF as part of national treponematoses grants has become an important and valuable projects form of Organizational aid to health adminis The awarding of fellowshups supplements trations and to individuals In the years the activities of demonstration and training 1947 53 196 fellowships and travel grants centres and fellowship funds are usually concerned with the control of venereal included in such projects in order to provide diseases and treponematoses were awarded the best available training for the medical (fig 25) at a cost of approximately a quarter officers and technical personnel who will of a million dollars The distribution accord bear the responsibility for developing the ing to WHO Regions was as follows Africa projects after the withdrawal of WHO 5 the Americas 21 South East Asia 47 assistance Fellowships and travel grants Europe 78 Eastern Mediterranean 30 and have also been given for studies abroad which Western Pacific 15 will serve WHO s ultimate purpose of FIG 25 DISTRIBUTION OF 196 TREPOVEMATOSIS FELLOWSHIPS BY COUNTRIES OF ORIGIN FROM 1947 TO 1953 60 ·and Treponematoses from 18 countries are undertakes investigations of certain funda participating is to evaluate the possible mental problems which can be handled only advantages and disadvantages of the use in a special research laboratory Also as of the new types of penicillin in indi previously noted it serves to train specialists vidual patients both in clinic practice and and technicians from various countries in mass campaigns These studies are in under the WHO fellowship programme and many ways parallel to the operational under programmes of other insututions research undertaken when PAM was first interested in laboratory research Much introduced in the treatment of the treponema interesting and important work is being done toses and when subsequent simplification of the significance of which increases as the injection techniques and dosage schedules years go by were evaluated Such research as an integral The first step was to isolate active strains part of WHO projects is profitable for the of treponemes from various WHO treponem modifications which may result in health atosis programmes in different parts of the techniques and campaign procedures can world so that they could be used for compar mean greater efficacy at less cost in selective ative studies 16 Infected material has been public health programmes prepared by members of WHO field teams Another study assisted by WHO is the inoculated into rabbits or hamsters and appraisal of extensive material made available forwarded by air to the Center So far 12 of by the Clinical Co-operative Group in Great the 16 strains obtained from patients with Britain A number of venereal disease venereal or endemic syphilis in Chicago clinics there have pooled follow up data on Meuco Iraq and Bosnia from cases of bejel different methods of syphilis treatment in the in Syria and Iraq and from yaws patients in comparative evaluation of which WHO is Thailand Haiti Indonesia and Samoa have assisting been successfully perpetuated in rabbits or Simularly WHO undertook in 1952 to hamsters No pinta strain has thus far been compile information on current practices successfully established experimental 10 leading venereal-disease clinics and among animals venereologists throughout the world in the It has been observed that there are persist treatment of early syphilis This study which ent differences between and within established ended late in 1953 and the results of which types and strains of treponemes It appears will be published in 1954 indicated a very that these differences are quantitative rather clear general trend towards reliance on than qualitative and it is believed that the penicillin alone more than 80/ of the 277 characteristics of a particular strain are based venereologists participating in the investiga primarily on its capacity to produce hyalur fion have adopted penicillin treatment onic acid The possible influence of environ without adjuvant therapy mental factors including temperature on the characteristics of types and strains of trepon emes is also being studied at the Center It THE INTERNATIONAL TREPONEMATOSIS has long been known that hot summer LABORATORY CENTER weather modifies the course of syphilis in experimental animals the influence of tem The International Treponematosis Labor perature on the development of skin lesions atory Center was established with WHO assistance at Johns Hopkins University Baltimore 10 October 1950 Трет тв нПаnd The Center DH & Sch K. (1953) Bu Wu Hith Org 47 in ·represent the achievements of international the epidemiologist the clinician and the co operation in the field of health Studies health administrator with technical informa of results in specific disease control methods tion to which he might not otherwise have which may be readily applied with modifi access cations to all countries surveys of the Experience has shown that another note geographical distribution of diseases and worthy source of technical information is to review articles prepared by outstanding be found in papers issued by the Organization experts on the basis of literature from all in limited number as mimeographed docu countries which have contnbuted to existing ments Such documents are intended pri knowledge--these are among the types of manly for members of expert advisory panels articles which may be considered to be or committees and for internal use by the internationally significant In addition staff or by laboratory and research institutes reports of surveys on specific subjects made with which the Organization has close by expert consultants on behalf of WHO working relationships These documents after conferring with relevant workers in can be made available to interested persons various countries and personal investiga but they are not destined for library files or tions covering wide areas as well as reports meant to be indexed in reference lists or or original findings made in the course of reviewed by medical journals Papers which WHO field programmes are considered to are considered of more lasting and general have international significance because they value are often included in one of the WHO are essentially the outcome of international technical publications as has already been co operation In following this editorial noted policy the Organization endeavours to make A list of WHO reports monographs a distinctive contribution to medical docu articles and other publications on the mentation by providing the research worker treponematoses may be found on page 74 INTERNATIONAL CO-ORDINATION OF RESEARCH The coordination and promotion of ological and other data accumulated in the research on health problems are among campaign against endemic syphilis in Bosnia the functions of WHO particularly when such This study is based on a mechanical punch research is directly related to Organization card system established at the Central Syphilis programmes or projects Such international Register in Sarajevo where copies of all research can be accomplished by special field records of the entire campaign are field studies or by supporting existing institu avauabie tions The present article attempts to give As was mentioned carlier comparative some idea of WHO s research actisities rela studies of PAM and the new repository tive to the treponematoses and their control benzylamine penicillin salts in syphilis yaus Operational research and special intestiga and pints are being co-ordinated by WHO in co-operation with leading national experts tions are carried out to appraise the use and in several countrics The purpose of these usefulness of various treponematosis-control investigations in which members of the WHO practices in individual projects For example Expert Advisory Panel on Venereal Infections work is under way to cvaluate the epidemi ·of the venereologist the treponematologist Standardization of antigens and the medical officer concerned with the Standardization of antigens has become control of venereal diseases and of the non feasible with the development in recent years venereal treponematoses of defined substances namely cardiolipin One of the basic changes in outlook in and lecithin which replaced the more laboratory work in recent years has been the uncertain lipoidal antigens obtained in the definition by WHO of the specificity of serological tests in terms of the treponemal past from animal tissues The more specific diseases as a group rather than in terms of cardiolipio antigens have now been accepted everywhere as the antigens of choice in the syphilis as was the case before 1952 How serodiagnosis of the treponematoses ever any conventional antigen for syphilis After several years of laboratory studies and the other treponemal diseases can under by members of the WHO Expert Advisory certain conditions give a false positive result Panel on the Serological and Laboratory If different serological techniques are applied Aspects of Venereal Infections and Trepoa quantitative reagin titre in one country will nematoses WHO in 1951 estabushed inter not necessarily be comparable with that in national reference preparations of cardiolipin another or for that matter with that in and lecithin by action of the Expert Com another laboratory in the same country mittee on Biological Standardization 18 This This is due not only to variations of has enabled laboratories and manufacturers method Results cannot be standardized all over the world to standardize their by competitive serological conferences be antigens against a known measure by tween authors of serological tests since obtaining samples from the Statens Serum variations in testing procedures the world over are considerable and particularly since institut Copenhagen These international reference preparations must however be the composition of antigens used and their reactivity also differ widely In the past replaced from time to time and continuous serologists endeavoured to measure study is therefore required one unknown-the titre or the amount of reagin A monograph by Mary C Pangborn the --by two others-either a variety of reagents discoverer of cardiolipin antigen and her (of which the constituents were largely associates at the Division of Laboratories and Research of the New York State Depart unknown) or a variety of methods (for which no standards whereby their ment of Health was published by WHO in 1951 19 performance could be judged) The aim of This monograph contains much useful information on the preparation and WHO has therefore been to work towards the standardization of the two basic un the chemical and serological testing of these antigens knowns which might be controlled-the A revised edition is due in 1954 reagents and the methods so that the un known titre or reagin can be more accurate Standardization of methods ly and uniformly measured In 1949 a WHO Serological Reference Laboratory The establishment of an international was set up at the Statens Seruminstitut in reference bank of strongly positive moder Copenhagen to conduct a series of studies ately positive and weakly positive reacting which might lead to the desired degree of freeze dried sera (measured by titre) against standardization of reagents and methods WHO I APS (195) 56 (A review of the Laboratory s work will be Pangbort, MC Mallader F T mpling Y N Beecher found on the next page) T Thompson, WR & Flynn, M R. (1951) C dulipi on gas Gegey (World Hith Organic on Afonograph Series No 6) there were ·1$ of special interest warmth having an this problem are now being co ordinated inhibitory effect during the incubation period through WHO of syphilis Such studies are particularly Another discovery at the Center has been interesting in view of the unitarian theory the adherence disappearance phenomenon that the differences among the treponemes which has been described in a recent causing syphilis yaws bejel etc may result publication 17 Specific techniques developed from one single ancestral type of treponeme s in connexion with this phenomenon having adapted itself to different environ have shown the presence of another specific mental conditions antibody in the serum of infected individuals Problems of the immunological relationship which is different from the reagins detected of different strains of treponemes are also by the usual flocculation or complement being studied as are the degree of immunity fixation techniques built up in infected rabbits judged by their The Center has carried out many important reaction to challenge with another strain the relationship between specific antibodies and comparative studies on the penıcıllın sen sitivity of treponeme strains received from the development of antibodies during the course of infection A substantial degree of various WHO field projects in order to watch for the possible appearance of penicillin cross immunity among the various strains of resistance a question clearly of great signific treponemes has been demonstrated although ance both to the medical world in general the results with bejel and yaws strains are less and to the mass campaigns under way clear than with different strains of syphilis It has also been shown by cross immunity against the treponematoses The Center has also been conducting investigations on the studies using the Treponema pallidum im potential efficacy of antibiotics other than mobilization (TPI) test that a close anti penicillin against treponemes these experi genic relationship among the treponemes is ments have shown that though all the drugs probable tested have some activity against T pallidum A new treponemal agglutination (TPA) penicillin is still the most effective known test has been developed by the Center the agent against treponemes Naval Medical Research Institute Bethesda Md and the Venereal Disease Experimental Laboratory at Chapel Hill NC The agglutination of killed INTERNATIONAL STANDARDIZATION OF T pallidum by the sera of syphilitic individuals SEROLOGICAL REAGENTS AND METIIODS had previously been attempted with varying success by a number of investigators but had Thc effectiveness of treponematosis not proved valuable as a diagnostic procedure control programmes depends to a certain owing to difficulties in maintaining a suitable extent upon the efficient conduct of serologic suspension of viable organisms A procedure al tests whether it be a question of the has now been found which eliminates these evaluation of the results in the treatment of difficulties and preliminary studies with syphilitic seafarers or of the comparative rabbit sera have shown a high degrec of appraisal of results of mass treatment correlation between positive agglutination campaigns against yaws as carried out in pilot and control areas of such campaigns and the presence of syphilitic infection Results with human sera have also been The laboratory remains essential to the work encouraging when suitable techniques have • Nelson, X. A, (1952) Puma 1719 been used A number of laboratory studies on in 64 ·cases been dealt with and if so only for from ten laboratories (Copenhagen Washing Orientation purposes) and (c) antigen pre ton Lyon Palermo Bordeaux Paris (2) pared at the Laboratory from the provisional Landstuhl Lille and Chambice) were com international reference preparations of car piled at the Laboratory in July 1953 and it diolipin and lecithins of 1951 and 1953 was found that the variation in titre was The research work on serodiagnostic great suggesting the need for further methods is concerned with lipid antigens investigation on the one hand and the TPI test on the Rabbits inoculated with T pallidum other (Nichols pathogenic strain) have been sent Shortly after the publication of the WHO to sit different laboratories in Europe The monograph on cardiolipin antigens (see attainment of optimal survival conditions Page 65) the serological techniques described for pathogenic T pallidum in vitro has been therein were tried out with a view to perfect and still is subject to intense study ing their performance The purpose was to In November 1950 14 specimens of blood enable tests for the acceptance or rejection of mainly from syphilitics were collected and new lots of cardiolipin and lecithin to be freeze dried serum was prepared for use in a performed by similar methods at the Division preliminary experiment in which the suit of Laboratories and Research of the New ability of freeze dried serum for serological York State Department of Health Albany evaluation as well as the keeping quality at NY and at the Statens Seruminstitut different temperatures was tested in the Copenhagen Copenhagen Laboratory and in laboratories Preliminary studies on the keeping qualities in the following cities Bergen Calcutta of lecithins and cardiolipin antigens have Chamblee London and Tel Aviv This been performed with the Copenhagen com pilot experiment resulted in the recommenda plement fixation technique Using this test tion that further studies on the value of method new lots of cardiolipin and lecithins freeze dried sera in the evaluation of serolo have been compared with the provisional gical methods be undertaken It was decided international reference preparations of car that 80 sera from selected donors (syphilitic diolipin and lecithids for 1951 and non syphilitic) should be freeze dried Cardiolipin antigens have been compared The Laboratory has thus far prepared with crude lipid antigens using different 19 freeze dried sera and has collected an types of seroreactions such as complement additional 28 sera from other laboratories fixation tube flocculation and slide floccula Early in 1953 samples of the first 30 sera tion the maturation phenomenon of cardio (some in duplicate) were sent out to a number lipin antigens has been studied in of laboratories of members of the Expert complement fixation experiments and by Advisory Panel on Serology and Laboratory nephelometric methods and the results of Aspects the various studies have been evaluated in In March 1951 the WHO Reference close collaboration with the Statistical Laboratory was requested to take part in Department of the Statens Seruminstitut the chemical analysis of samples of cardio In September 1952 the Laboratory was lipin and lecithin for the Expert Committee invited by WHO to take part in a co operative on the Unification of Pharmacopoeras Spe study on the TPI test The first WHO TPI cifically the Laboratory undertook the phos control serum was prepared in Copenhagen phorus analysis and the determination of dry it was distributed to 25 laboratories in weight In 1953 the chemical results from March 1953 Preliminary quantitative results other laboratories were studied 67 ·which existing serological methods in use anywhere in the world can be compared 15 the logical second step in the standardization work of the WHO Reference Laboratory at Copenhagen The work on freeze drying has been carried out by a number of laboratories (Bombay Caracas Coonoor Johannesburg London Madras Naples and Osaka) in co operation with the Copenhagen Laboratory which has in turn sent sera for testing to 15 labora tories in different parts of the world (Albany Bergen Bombay Cairo Calcutta Caracas Chamblee Coonoor Johannesburg London Naples New York Osala Tel Aviv and Trondheim) so as to ensure as wide a basis as possible for the planned reference bank At the seventh session of the WHO Expert Committee on Biological Standardization held in 1953 it was decided that the stability of freeze dried sera had been proved in the preparatory studies carried out by the co operating laboratories and that actual international reference preparations could now be established Action is being taken accordingly and it will therefore be possible in the course of 1954 for national labora tories all over the world to obtain samples of international reference sera from Copen hagen-enabling them to guide serological workers in their countries in carrying out tests with a defined degree of seroreactivity determined by the titres of the frecze dried sera--in addition to obtaining defined cardio lipin antigen reference preparations Standardization of methods has also been fostered by the inter laboratory erchange of sera for other purposes for instance for determining the stability of sera m postal transmission Twenty sıx laboratories (Montreal Otlana Albany New York Copenhagen Chamblee Havana Mexico Montevideo Reykjavik Lisbon London Brussels Bergen Zurich Palermo Vienna Helsinki Ankara Tel Aviv Cairo Baghdad Teheran, Calcutta Colombo and Jogjakarta) and a number of W HO field teams (eg in Guatemala Simla and Bangkok) have participated in various studies of this kind Parallel work has been undertaken by the Venereal Disease Research Laboratory and Training Center in Guatemala which has aimed at the standardization of serological tests in Central America under the auspices of the Pan American Sanitary Bureau and WHO Assistance in serological work has also been given in that part of the world by a number of training courses which have been attended by many technicians from most of the Central American countries The influence of these courses has already shown itself in the syphilis-control pro grammes in the Americas As already mentioned much of the work in standardization of serological reagents and methods has been carried out by the WHO Serological Reference Laboratory in Copenhagen in cooperation with a number of national laboratories To illus trate the type of work undertaken at the Laboratory a review of some of its activities is given below THE WHO SEROLOGICAL REFERENCE LABORATORY The work of the WHO Serological Reference Laboratory Copenhagen falls under four principal headings (1) evaluation of antigens for the serodiagnosis of syphilis (2) testing samples of blood or serum trans mitted to the Laboratory (3) research work on serodiagnostic methods and (4) training of personnel in the use of serodiagnostic methods In return for this work WHO makes a yearly grant to the Laboratory Three different categories of intigen have been tested (a) antigen used or to be used by WHO field teams (work with this type of antigen has predominated) (b) antigen from producers (only in a few instances have such ·CONSOLIDATION OF RESULTS nd survey 357 06 nd surve The more specific objectives of internation TABLE VIE RESULTS OF SAMPLE RESURVEYS AFTER 6-12 MONTHS IN CONTROL AREAS OF al co-operation in treponematosis control FOUR YAWS CONTROL PROJECTS have already been outlined (page 33) and the Cases ol yaws contributions which selective public health Project area Number e amined nurrber 9 projects against these infections can make Hat 1 1 survey 97 4 160 426 towards the highest attainable standard of health "I have been suggested However 12 915 103 08 any group of public health workers which Indones a 1st survey 1632 219 attains a high degree of specialization may 2nd s rvey 1 567 57 sometimes tend to overlook the fact that in Phipp nes 1st survey 16 072 2.900 180 the final analysis its work will be productive 1€ 481 400 .5 only if supported by a general programme Th iad 1st s tvey 313 338 56 407 180 of disease prevention Work in conjunction 2nd survey 3.3 800 2.241 06 with other health activities (maternal and child health malaria tuberculosis etc ) is and control areas desirable whenever initial exploration of the This is illustrated for health problems in an area shows technical yaws in table VII for endemic syphilis the and administrative advantages As has evidence already given in table VI (page 43) already been mentioned selective public and fig 18 (pages 44 5) speaks for itself in health projects are potential bridgeheads for other instances the results have been less extension into broader multiphasic public good and the number of new cases repre health activities both in urban and rural sented by reinfections infectious relapses or areas and provide a method of strengthening cases reintroduced from neighbouring areas the structure of local as well as national has caused some concern This question is to health services-a basic aim of WHO? some extent connected with the intensity of In the past the advantages and disadvant the treatment of household and community ages of the approach to disease control and to contacts in the different projects the improvement of health in general by the It is evident that the good initial results stationary urban clinic and rural health centre obtained by a mass sweep" of the popula system have been realized But little informa tion with penicillin must be followed by tion on mass campaigns has been available resurveys The mass treatment phase of until recent years when extensive malaria campaigns against any of the treponematoses tuberculosis and treponematosis control is but the first step towards full control and activities have been undertaken by health eradication of the infection Control efforts administrations with international assistance must be continued even after that phase That the non venereal treponematoses can follow up examinations and where necessary be controlled by mass application of penicillin re treatment must be carried out if the IS indicated by the results observed in benefits of the original action are not to be resurveys conducted in a number of sample lost Governments must provide for this Fm p cambl ! the Consta to [th Wld I sth continuity in their planning and in drawing up I World Heal ganzzati (1933) Indbook their budgets Past and ultimately unsuccess basle d cumet 4,6 Sed tion, P 3 Bonne WMG the T&Rynold FW (1993) B! WW HIO II 371 Gth T Reynold FW Kras P RR (1933) Bimd594 O RAAJZE od Wulco 69 ·TREPONEMATOSIS CONTROL AS A MEANS TO AN END Health activities as a means of international cooperation are not new but can be traced as far back as the 14th century However there has been a significant change in emphasis and objectives since those early times From the dissemination of information and the setting up of quarantine regulations to prevent the spread of pestilential diseases from one country to another international health activities have been extended to the pooling of knowledge experience and resources to provide direct assistance to countries in communicable disease control and in the general promotion of the health of their people A principal objective has now become the control and eventual elimination of diseases of public health importance wherever they occur Like most other projects of assistance to governments treponematosis control whether it be through an urban programme for the control of venereal syphilis based on stationary clinics or through a mass campaign against a non venereal treponematosis in 1 rural area can also serve as a bridgehead for the development of local health services At some point in the treponematosis control programme, the gains should be consolidated as part of general communicable-disease control The activities required to keep the infection at a controllable level-or to eliminate it completely-should be integrated into the local or national health services This integration represents a new challenge in modern public health work As the need for intensive treponematosis-control measures diminishes general public health activities of gradually increasing scope may then take precedence over the fight against this specific infection Through long term planning treponematosis control may thus become a means to an end-namely the strengthening of local health services 68 ·ECONOMIC ASPECTS OF TREPONCMATOSCS CONTROL The economic value of the health of its of certain preventive measures such 45 inhabitants to a community is a subject obligatory premarital serological examina which is receiving the increasing attention tions is the State of California for example of governments Studies on this subject are It was estimated that for the years 1949 still insufficient particularly as regards the 1950 and 1951 a total loss of $6 339 274 in less-developed areas but attempts to trans productive manpower and domiciliary care late health into terms of economic product was prevented by this screening method and ivity and gain have shown how serious are that this meant a yearly saving to the State the losses attributed to ill health and how of $1 275 3647 profitable can be action against them The economic loss caused by the trepone Such attempts can be only approximations matoses is reflected in the age groups from yet they have provided a basis for interesting which they take their toll in the form of and stimulating discussion incapacitation invalidism or the need for Several illustrations of this thesis are special medical care It is obvious that provided by the treponematoses It has been infancy and carly childhood are a period of estimated that 100 000 man days of labour investment for the family and community are lost annually as a result of venereal It is considered for example that in the USA diseases in Southern Rhodesia and in the non productive phase of life extends to Haiti where yaws was widely prevalent the age of 18 years and that this period among the rural population the 35 000 to entails an investment in the child up to that 55 000 persons treated monthly in the joint age of more than $7 000 for 1 family with WHO/UNICEF programme have meant the an annual income of $2500 $ In other coun return to work of approximately 100 000 tries particularly in agricultural areas and incapacitated persons and a consequent where child labour in industry is common increase national production of the child begins to be productive at a much $5 000 000 a year earlier age even SO it is almost certain In some countries it has been possible to that up to the age of 15 years the investment estimate directly the loss of manpower in a child greatly exceeds the economic attributable to venereal syphilis in military forces civilian life and industry and to What does this mean in populations in calculate the co t of institutional care of late which yaws or other treponematoses are syphilitics Thus the disability and cost prevalent? It has already been pointed out to the nation from syphilis in the USA (page 15) that the age distribution of the non is illustrated on page 73 • EfTorts have also senereal treponematoses is different from been made to calculate indirectly the value that of venereally acquired syphilis since the Wow C.E. A (1951) 7% former are primarily diseases of childhood ilka and the pa hing 19 NHIth Org ! ! MSpA while the latter affects those who have les N 7) P 30 US Dp rtment of St (1950) Polis reached sexual maturity This is illustrated dlopmm'lly nde de pd as Wgton, DC (Publ Lion 3719 Eco tu Coope Co dit, P K&B w AP (1953) Ame / pbl HIL I Security Agency Publ_Hith Service (195) VD 43 680 Fat Sheet, D VS10 ne 1 D case Office Stat tes D blin, LII tka, AI & Sp z im M (1947) TA New YK SO 10 return per N P & 10 Se th 20) Fd 1 mbe 9 M 71 ·70 70 FIG 26 INCIDENCE OF YAWS IN HARKERS HALL AREA ST CATHERINE. JAMAICA 40 80 0 2 20 10 0 1902 190 194 1915 1944 1947 1948 3949 1951 1952 Ordinales attack rate per 1000 inhabitants Mass treatment was car ried out during the years 1942-45 1947 and 1951 52 but the results were not con solidated and the efforts were thus largely wasted Ndul re a labr the ar 1949 50 1950 ful eradication campaigns have made this place in a few decades There is good reason abundantly clear the rise and fall in the to hope that the mass campaigns themselves incidence of yaws shown in fig 26 are due contribute substantially to the health educa largely to insufficient follow up measures tion of the public through the convincing When the reservoir of infection has been complete disappearance of lesions and the sufficiently reduced the consolidation of the rapid cure results may be continued under general public Parallel health projects in fields other than health programmes This will of course the treponematoses also help substantially depend on the existence or creation of towards this change in the social environ permanent rural health facilities in the areas ment which it should be said has already concerned It should be possible for health begun in many areas WHO is concerned administrations to take advantage of the with all aspects of public health and social progress made and to reinforce the rural medicine and especially with the training health administrations with staff previously of personnel in preventive medicine and engaged in the mass campaigns Further hygiene Considerable success is being planning by health administrations WHO achieved in the control of malaria and other and UNICEF is needed if vast efforts and insect borne diseases such as yellow fever funds are not to be wasted and if recurrence Immunization against tuberculosis with BCG of the treponematoses in endemic or hyper is widespread in some arcas immunization endemic form is to be avoided projects against diphtheria and pertussis have Whether the victory will be final also been encouraged Epidemics of poliomyelitis depends on the degree of social advancement and influenza call for prompt action and The epidemiological research Health education and activities in in the areas treated maternal and child health nutrition and environment is changed by mass treatment but there must also be a corresponding change social and occupational health are being promoted and problems such as drug addic in the social environment-and that as soon ton and chronic discases are not crcluded as possible-if it is not to contnbute to a from consideration Achievements in such recurrence of the spread of the trepo a yiriety of fields cannot fail to leave an nematoses What has taken many countries impression in underdeveloped arcas centunes to achieve in the past can now take ·M even more willing to work and work well This by out Penicillin in mass diseases like syphilis itself tends to raise productivity it is also true that, and yass is indeed an important pacemaker according to the panaple of cumulate causation of this kind an improved health standard will per se always teod to improve all other componest factors in the plane of Lyng Millions of people are incapacitated by In effect, medical advances can serve as the treponematoses during the most propacemakers of social change a view ductive period of their lives in areas where which was pointed out to the United Nations national development requires ablc bodies Social Commission “In the underdeveloped to assist in agricultural industrial and other areas release of the resources of the programmes for cconomic expansion In countries from the tangled undergrowth of such areas the widest possible application mass disease is a prerequisite for develop- of penicillin in trepancmatosis-control pro grammes is a means to an end and represents The WHO Expert Committee on Venereal an element in social and cconomic progress Infections and Treponematoses 18 has pointed Much remains to be done nationally and Vouted Natoon (1952) Ilminary sport on the worll social internationally but the impact of the work rua low with special / 1 mandards of Hiing New Ytt under way has already begun to be discernible hapter IILP 32 (document E, CV.5.7267/R¢ 1) HUA Org recku R Ser 1953 6 7 in many parts of the world ment 16 - DISABILITY FROVE AND COST OF SYPHILIS IN THE USA Estimated disability from syphilis in man-years Hospitalization for insanity from syphilis (1950) Disability from cardiovascular syphilis including aneurysm (1949) Disability from locomotor ataxia (1949) Disability from syphilic blindness (1949) 42,438 12,332 2,080 39 000 Estimated annual cost of syphilıtıc psychosis and syphilitic blindness in US $ 41 162 000 86 489 000 Maintenance of patients with syph:litic psychoses (1950) Loss of income by patients with syphilstic psychoses (1950) Loss of State and Federal income tax payments from patients with syphilitic psychoses (1950) Maintenance of syph litic blind (1949) 6 790 000 18 750 000 Federal Security Agency Public Health Service (19527 VD Fact Sheet Diis Office of Statas , ls ue numbe 9 Vence al Disease 73 ·disease does not play an important role as natural population check Yaws is more of a crippler than a killer and yaws control programmes mean that there will be increased manpower for productive purposes rather than more mouths to feed FIG 27 OVSET OF YAWS (JAMAICA) AND DISCOYERY RATES FOR EARLY SYPHILIS (BALTIMORE) BY AGE GROUPS . 30 SO 40 in fig 27 based for yaws on material from an area in Jamaica and for venereal syphilis on data ior an urban area in the USA (Baltimore) 10 It will be seen that more than 42 5 persons per 1000 had acquired Yaws before the age of 15 and that the attack rate after that age was only 1 5 per 1 000 In venereal syphiles on the other hand the rate was only 2 12 per 1 000 among those under 15 years of age and much higher thereafter From a social and economic standpoint however the result in terms of productive manpower is the same in yaws the early onset of the disease results in a variety of disfiguring and invalıdıng manı festations including locked ankles and elbows and plantar and palmar lesions during the most productive years of life in venereal syphilis the productive age groups are attacked directly with consequent in mediate absenteeism and incapacitation for work and with neurological cardiovascular and other systemic involvement which later causes a further important loss of manpower of the disease is untreated Another economic factor is the neonatal mortality attributable to the treponematoses The higher death rate among congenitally syphilitic infants compared with that of children born of healthy mothers has long been recognized Moreover venereal syphilis is known to be the cause of approximately half the stillbirths and abortions in untreated syphilitic women That this is true to some extent also among pregnant women suffering from endemic syphilis has been contended by There is some evidence that yaus too may result in increased infant mortality :: although it is generally believed that this 40 30 30 20 20 10 10 . S 13 15 20 25 35 40 45 50 55 10 Ordinates annual rates per 1000 population A -- Yaws in Jamaica B-Syphilis in Baltimore Grin 11 Apart from these profit and loss considera rations there are wider logical grounds on which health programmes should form part of general programmes for social and economic development wherever possible Myrdal 15 for example has said "It is true that an improved health standard will imply both a more favourable age structure of the population with a large part of it in the productise ages and in every age group a people more able and HILL R (1953) Monst the factors in the pidemiolory / w H I K Alth Organizato Filma tonal Sympo lum or Ytrol Geneva (World Wali Orgente lom Not topi Scrier No 13 p 17 Tener T3 Dyu R Clark E.O & Arlbe MF (1943) Am J Hye 37 273 Gna, E. L. (1951) Epidemiology od onih radom ITPAITA report of a rass-treatme I comply Bonia, Geneva (World Health Organization Prograph Serie No 1 P 41 Saunders, O M2 Muench H1 (1937) AW H 26 4.3 Myrdal (1991 Chro HI A Org 6 211 ·GRIN E, Endemic syphilis in Bosnia clinical and epidemiological observations on a successful mass treatment cam paign Bull I'm Hith Org 7 1 TURNER TB & HOLLANDER DH Studies on treponemes from cases of endemic syplulis Bull WW Hlth Org 7 75 KVITTINGEN ) CUTLER J C MCCULLOUOI JA ROSE, E, FORD V TAMPI R B SEN S & LAKSHWIR Serological aspects of a syphilis-control programme in the Ghund Atta, Himachal Pradesh, India Bull wid Hith Org 7 83 1993 TURWER TB HOLLANDER, D H & SCHAEFFER A Biological investigations on treponemes Bull Hd Huth Org 8 7 HILL, KR Non specific factors in the epidemiology of yaws Bull Hd Hlth Org 8 17 LEVITAN S RODRIGUEZ C. JACOBS J C. PETRUS E & DURAND J B The treatment of Infectious yaws with onc injection of penicillin Bull Bild Hlih Org 8 35 KITCHEN DK & REIN C.R. Tumc-dose relation in penicillin therapy with special reference to yaxs laboratory basis for effective therapy Bol wld Hlth Org 8 77 REIN CR & KITCHEN Dh. Tume-dose relauon in penicillin therapy with special reference to yaws clinical basis for effective therapy Bull Hd Hlth Org 8 91 HILL, KR Antibiotics other than penicillin in the treatment of yaws Bull Bld Hlth Org 8 107 HACKETT CJ Extent and nature of the yaws problein in Africa Bull wld Hlth Org 8 129 VAUCEL, MA. Le pian dans les territoires aſncains français Bull Bld Filth Org 8 183 JUNGAL WALLA, N Planning for yaws control in South East Asia Bull Bld Huth Org 8 213 GUIMARÃES FN Yaws in Brazil Bull #ld Hith Org 8 225 REN CR Diagnostic aids in mass treatment campaigns against yaws Bull Hd HIth Org 8 245 PETRUS E LEVITAN S I AOLIELLO A & NICOL, R La campagne antipianique en Haft: Bull " Hith Org 8 261 SOETOPO M & Wasmo R Experience with yaws control in Indonesia preliminary results with a simplified approach. Bull Wid Hlth Org 8 273 HACKETT C. J Consolidation phase of yaws control experiences in Africa Bull Wid Hlth Org 8 299 CRUZ AH Integration of yaws control into the permanent health structure of the Philippines Bull Wid Hith Org 8 345 TROUPIN JL REYNOLDS FW & GUTHE T Yaws control - an opportunity for promoting rural health services Bull Wid #lth Org 8 355 BOVVE #M GUTHE, T & REYNOLDS FW The role of the World Health Organization in yaws control Bull wid Hith Org 8 371 KEENY SM The role of the United Nations International Children s Emergency Fund in yaws control Bull Wid Hith Org 8 379 75 ·PAPERS ON TREPONEMATOSIS CONTROL PUBLISHED BY WHO Bulletin of the World Health Organization 1949 GUTHE T Venercal diseases in Ethiopia Bull I ld Hith Org 2 85 International control of venereal disease excerpts from the report on the second session of the Expert Com mittee on Venereal Diseases Bull W Hlth Org 2 139 MARIONEY J F & ZWALLY MR Observations on the serodiagnosis of syphilis Bull Mld Hlth Org 2 227 THOMAS EW Rapid treatment of syphilis with penicillin I A suney of the problem Bull Hd Hilch Org 2 233 THOMAS E. W Rapıd treatment of syphilis with penicillin II Penicillin in prenatal and infantile syphilis Bull W1 Hlth Org 2 249 1950 Bull Wid Hlih DELIERKUNST A MILGROV F Complement fixation reactions with cardiolipin antigen compared with Kahn reactions Org 2 687 CUTLER JC Survey of vencreal diseases in Afghanistan Bull / Hlth Org 2 689 1951 PANGBORN MC MALTANER F TOMPKINS V N BEECHER T THOMPSON W R & FLYNN MR Cardiolipin antigens Bull Bld Hlth Org 4 151 Hill, I KODUAT R & SARDADI M Atlas of framboesia a nomenclature and clinxal study of the skin lesions Bull H I HIth Org 4 201 1952 CUTLER J C., KVITTINGEN I ROSE, E McCULLOUGHTAMPLAR B. SEN S PARMAR, C & LALG Mass treatment of syphilis in an Indian province report of the World Ficalth Organization Venereal Discase Demonstration Team in the Ghund arca of the Himachal Pradesh India Bull wild Illah Org 5 377 KUITTINGEN J., McCULLOUGAI J C., TAUPERB & BRAILA J J Significance of rapid serological testing for syphiles in field surveys Bull wil nih Org 5 473 KVITTNGEN CUTLER, JC. GUEVARA J A MCCULLOCH JC Rose E., FORD V TAMPT R. D SENS LAKSIHIR KHAN J & DASS, P Scrological tests for syphilis in lepers tendency for various antigens to give false positive reactions HIJ Hlth Org 5481 GHORPADE, MY Comparison of two commercial Meinucke antigens report on the use of three different qualities of saline in the preparation of each antigen for stological testing Bull fyld Hilih Org 3 313 Bull ·REN CR KITCHEY, D K, MARQUEZ & VARELA, O Penicilina de accido retardada en el tratamiento del mal del pinto en el campesino mexicano studio clinico y xerologico Bol Ofic sanit pan-amer 33 95 BAUER, TJ Tratamiento y control modercos de las enfermedades venéreas Bol Ofic sant par amer 13 105 Sour G MODEZ, J & GUZMAS M Reacciones serológicas para sifilis presuntamente positiyas falsas en la América Central 111 Relacon con el contenido de proteina albumına y globulina en el suero Bol Ofic sanit pan-amer 33 110 GAYOSO, PC Mérodos modernos de control de las enfermedades venéreas Bol Ofic sanli pon-amer 33 116 FUNES, I M. & AQUTLAR, C. Luz La solución de mafarside orvus ca la profilaxis de la blenorragia en la mujer Bol Ofic sandt panamt 33 121 SAMAME, O E Naturaleza y extensión del problema del pian en las Amétxas Bol Ofic sanit parames 33 126 GOODMAN, H Metodo para vepcer la tenuencia de los enfermos venéreos revelar sus contactos Bol Ofe samt pan-ome 30 142 SIMPSON, WO & MURPIIY V Neces dad de mejorar la formación profesional de las enfermeras de Venetcologia Bol. Ofc banli pan-amer 33 146 1953 Bovy, W M GUTHR, T & REYNOLDS, FW El Papel de la Organización Mundial de la Salud en el control del man. Bol Ofic sonje pan-am 34 34 EDMUNDSON WF Control antivenérco por la aplicación profilactica de perucilena mupos muy experien Lol Of conll pan-amer 344 347 GLTMARTES, FN El pian en Brasil. Bol Ofic sanit panamer 34 468 ROBERTS, PW Informe clanco sobre el empleo de la penicilina en el tratamerto de 100 ans er mal wen In sonil pan-amer 34 542 SALAS, AC Control de las enfermedades venéreas en la zona fronteriza Meranti tarpt of #!! pan-amer 35 124 GUEVARA, JA & MASI, DA Control de las enfermedades venéreas en el Paraguay Pal Ofic canli pornire VW HILL, KR Tratamiento del pian con anubioucos distintos de la per kilina Of #nit point EDMUNDSON WF Rico A. L. & OLANSKY S Estudio clincoserológica del mal de pirto Bol Ofic sanit paramer 1 Mostraples Hitl, K. R. KODUAT R & SALDADI M Alles of framboesia (Horld Health Organization M m gasp turint this where ***** w Hall 11/1 Hlth Org 1951 4 2011 PANGPORN M C., MALTANEX P., TOHTO V NI Truns tv, VI 1!! Cardiol pin antigens (World Health Organizalm Mouph Ante Studi Hah Org 1951 4 151) ·Boletin de la Oficina Sanitana Panamencana 1949 WRIGHT RD & NICHOLSON FP Treatment as a factor in the control of the senereal diseases Bol Ofic sanıf pan-amer 28 462 Courrs WE Organización de la lucha antivenerea bases principales en que actualmente debe apoyarse una campana Bol Ofic sanit pan-amer 28 545 1950 ARNOLD RC & MAHONEY JF Función de los antigenos de cardiolipina en la serologia de la sífilis Bol Ofic sanit pan-amer 29 397 Tecnica de floculación en portaobjetos de VDRL prueba de floculación en tubo de VDRL prueba de VDRL para llquido cefalorraquídco Bol Ofic sanit pan-amer 29 509 THOVEJ V Modificaciones que deben hacerse a las actividades educativas antivenéreas de acuerdo con los progresos registrados en su terapéutica con el uso de los antibióticos Bol Ofic sanıt pan amer 29 945 GOODEN DR Influencia de un programa profiláctico penicilinico en la incidencia de las enfermedades venéreas Bol Ofic sanıt pan-amer 39 1051 1951 SAMIAME, G Profilaxis sistémica anuvederea informe preliminar sobre el programa de Tijuana BC. Bol Ofic sanil pan-amer 30 42 CUTLER JC & Stour G Problemas serológicos en Centro América Bol Ofic sanıt pan-amer 30 321 Control o erradicación de las enfermedades renéreas Bol Ofic sanit par-amer 31 169 (Editorial) REON CR Problemas en el serodiagnóstico de la s[fuis Bol Ofic sanit pan-amer 31 105 KITCHEN D Penicilinoterapia moderna desenvolvimuento eficacia reacciones Bol Ofic samit pan-amer 31 118 BREWER FA Los nuevos antibióticos en el tratamiento de las enfermedades venéreas Bol Ofic sani! pan-amer 31 127 SANCHEZ PEREZ, R. Epidemiologia de las enfermedades venéreas Bol Ofic sanit pan-amer 31 132 STOUT GW & REYNARD R Primera encuesta serologica centroamericana Bol Ofic sanit pan-amer 31 141 SAMAME, G Organización de una división de control de las enfermedades venéreas Bol Ofic sanit pan-amer 31 151 la Oficina Sanitaria Panamericana, Oficina Regional 1952 SAMAME, G Programas de control de las enfermedades venéreas de la Organización Mundial de la Salud. Bol Ofic sanit pan-amer 32 37 STOLT G GUZMAN M & SCRIMSHAW NS Reacciones scrológicas para sifilis presuntamente positivas (alsas en la América Central distribución. Bol Ofic sant paramer 32, 206 Reacciones scrológicas para sifilis presuntamente posutras falsas ca la América Central Il Relación con el lado ascórbicomboflawina fosfatass alcalina carotina y vitaminas A y E en el suero sanguine Bol Ofic sanit pan-amer 32, 521 I Incidencia y ·REIN, C. R., KITCHEN D L. MARQUEZ F & VARELA, G Penicilina de acción retardada en el tratamiento del mal del pinto en el campesino mexicano estudio clinico y scrológico Bol Ofic sant paramer 33 95 BAUER, TJ Tratamiento y control modernos de las enfermedades venéreas Bol Ofic sanit panamer 33 105 Stout G MENDEZ, J & GUZMAN M Reacciones serológicas para sifilis presuntamente positivas falsas en la Aménca Central. III. Relación con el contenido de proteina albumina y globulina en el suero Bol Ofic sanut pan-amer 33 110 GAYOSO PC Métodos modernos de control de las enfermedades venéreas Bol Ofic sanit pan-amer 33 116 FUNES, J M & AGUILAR, CLUZ La solución de mafarside-orvus en la profilaxis de la bledorragia en la mujer Bol Ofic sanit pan-amer 33 121 SAMAME GE Naturaleza y extensión del problema del pian en las Américas Bol Ofic sanit pan-amer 33 126 GOODMAN H Método para vencer la renuencia de los enfermos enéreos a revelar sus contactos Bol Ofic sanıl pan-amer 33 142 SIMPSON W G & MURPHY V Mecesidad de mejorar la formación profesional de las enfermeras de venereologia Bol Ofic sanır Dan-amer 33 146 1933 BONNE, W M GUTH, T & REYNOLDS F W El Papel de la Organización Mundial de la Salud en el control del pian Bol Ofic sanıt pan-amer 34 340 EDMUNDSON WF Control antivenéreo por la aplicación profilactica de penscılına a grupos muy expuestos Bol Ofic sanit pan-amer 34 347 GUIMARXES FN El pian en Brasil. Bol Ofic sanil pan-amer 34 468 ROBERTS PW Informe clínico sobre el emplco de la penicilina en el tratamiento de 100 casos de mal de pinto Bol Ofic sahil pan-amer 34 542 SALAS A. C Control de las enfermedades venéreas en la zona frontenza Mexicana Estadounidense Bol Ofic sanıl pan-amer 35 124 GUEVARA, J A & MASI DA. Control de las enfermedades vedereas en el Paraguay Bol Ofic sanit pan-amer 35 132 HILL, L, R. Tratamiento del pian con antibióticos distintos de la penicilina. Bol Ofic sant pan-amer 35 147 EDMUNDSON WF Rico A L. & OLANSKY S Estudio clinicoserológico del mal de pinto Bol Ofic sanit pan-amer 35 163 Monographs HILL, K. R. KODVAT R&SARDADI M Atlas of framboesia (World Health Organt ar on Monograph Se ies No 5 also published in Bull Md Hith Org 1951 4 201) PANGBORN MC MALTANER F TOMPKINS V N BEECHER, T THOMPSON W R & FLYNY MR. Cardiolipın antigens (World Health Orgam ation Monog oph Series No 6 also published in Bull Wid Hith og 1951 4 151) ·Boletin de la Oficina Santana Panamericana 1949 WRIGHT RD & NICHOLSON FP Treatment as a factor in the control of the venereal diseases Bol Ofic sanit pan-amer 28 462 COUTTS VE Organización de la lucha antivenerea bases principales en que actualmente debe apoyarse una campada Bol Ofic sanir pan-amer 28 545 1950 ARNOLD RC & MAHONEY J F Función de los antigenos de cardiolipina en la serologia de la sifilis Bol Ofic sant pan-amer 29 397 Técnica de floculación en portaobjetos de VDRL prueba de floculación en tubo de VDRL prueba de VDRL pars liquido cefalorraquideo Bol Ofic sanit pan-amer 29 509 THOME J V Modificaciones que deben hacerse a las actividades cducativas antivepéreas de acuerdo con los progresos registrados en su terapéutica con el uso de los antibióticos Bol Ofic sanit pan-amer 29 945 GOODEN DR Influencia de un programa profilactico penicilnico en la incidencia de las enfermedades venéreas Bol Ofic sant pan-amer 39 1051 1951 SAMAME, G Profilaxıs sistémuca antivenérea Informe preliminar sobre el programa de Tijuana BC Bol Ofic sanir pam-amer 30 42 CUTLER JC & STOUT G Problemas serológicos en Centro América Bol Ofic sanit pan-amer 30 321 Control o erradicación de las enfermedades venéreas Bol Ofic sanit pan-amer 31 169 (Editorial) REIN C. R Problemas en el serodiagnóstico de la sífilis Bol Ofic sanit pan-amer 31 105 KITCHEN DK Penicilinoterapia modema desenvolvimento chcacia reacciones Bol Ofic sanit pan-amer 31 118 BREWER F A Los nuevos antibióticos en el tratamento de las enfermedades venéreas Bol Ofic sanit par amer 31 127 SANCIEZ PEREZ R Epidemiologa de las enfermedades venéreas Bol Ofic sanit pan-amer 31 132 STOUT GW & REYNARD R Primera encuesta scrológica centroamericana Bol Ofic sant pan-amer 31 141 SIMAME, G Organización de una división de control de las enfermedades venéreas Bol Ofic sanit pan-amer 31 151 la Oficina Sanitaria Panamericana Oficina Regional 1952 SAMAME G Programas de control de las enfermedades yenéreas de la Organización Mundial de la Salud. Bol Ofie sanit pan-amer 32, 37 STOUT G GUZMAN, M & SCRUSLAW NS Reacciones scrológicas para sífilis presuntamente positivas falsas en la América Central distribución. Bol Ofic sanit par-amer 32 206 Reacciones serológicas para sifilis presuntamente positivas falsas en la América Central. !! Relación con el ácido ascórbico nboflarna, fosfatasa alcalins carolina y Milaminas A y E en el suero sanguineo Bol Ofic sarut pan-amxT 32, 521 I Incidencia y 76 ·REN CR.KITCHEN D , MARQUEZ, F & VARELA, O Penicilina de accada retardada en el tratamiento del mal del pinto en el campesino mericano estudio clinico y serológco Bol Ofic sanit pan-ame 33 93 BAUER, TJ Tratamento y control modernos de las enfermedades venéreas Bol Ofic samt pon-omet U 105 STOUT G., MENDEZ, J & GUZMAY M Reacciones serológicas para sffilis presuntamente positivas falsas en la América Central II Relación con el contenido de proteina, albumina y globulina en el suero Bol Ofic sanit pan-amer U 110 GAYOSO PC Métodos modernos de control de las enfermedades venéreas Bol Ofic sanit pan-amer 33 116 FUNES, J M & AGUILAR C. LUZ La solución de mafarsıdcorvus en la proflavus de la blenorragia en la mujer Bol Ofic sanit paruamer 33 121 SAMME GE. Naturaleza y extensión del problema del pian en las Américas Bol Ofic santul pan-amer 33 126 GOODMAN H1 Método para vencer la renuccia de los enfermos venéreos a revelar sus contactos Bol Ofic sanit par amer 33 142 SIMPSON WG & MURPHY V Necesidad de mejorar la formación profesional de las enfermeras de venereologia. Bol Ofic sanit pan-amer 33 146 1953 BONNE, W M GUTHE, T & REYNOLDS, FW El Papel de la Organización Mundial de la Salud en el control del pian. Bol Ofic sans pan-amer 34. 3-40 EDMUNDSON WF Control antivenereo por la aplicación profiláctica de penicilina a grupos muy expuestos. Bol Of c sanit par-amer 34 347 GUIMARÃES, FN El pan en Brasil. Bol Ofic sanit pan-amer 34 468 ROBERTS PW Informe clinico sobre el empleo de la penicilina en el tratamiento de 100 casos de mal de punto Bol Ofic sanit pan-amer 34 542 SALAS A C. Control de las enfermedades venéreas en la zona fronteriza Mexicana Estadounidense Bol Ofic saru! pan-amer 35 124 GUEVARA, A & MASE, D A. Control de las enfermedades venéreas en el Paraguay Bol Ofic sanir pan-amer 35 132 HAL, KR Tratamiento del pian con antibióticos distintos de la penscılına Bol Ofic sanut pan-amer 35 147 EDMUNDSON WF RICO AL & OLANSKY S Estudio clinicoserológico del mal de pinto Bol Ofic sarut pan-amer 35 163 Monographs Hai, K R. KODUAT R. & SARDADI, M Atlas of samboesa (Hold Health Organi ation Monograph Series No 5 also published in Bull Wid Hlih Org 1931 4 201) PANGBORN MC MALTANER F. TOMPKINS V N BEECHEX, T THOMPSON W R. & FLYNN MR Card oi pir ant gens (World Health Organ at on Monograph Series No 6 also published in Bull w Hith Org 1951 4 151) ·el ácido ascórbico riboflay na fosfatasa alcalina carotina y vitaminas A y E en el suero sanguineo Boletin de la Oficina Sanitaria Panamericana 1949 WRIGHT RD & NICHOLSON FP Treatment as a factor in the control of the venereal diseases Bol Ofic sanit pan amer 28 462 COUTTS WE Organización de la lucha antivenerea bases principales en que actualmente debe apoyarse una campana Bol Ofic sanit pan-amer 28 545 1950 ARNOLD RC & MAHONEY JF Función de los antigenos de cardiolipina en la serologia de la sffilis Bol Ofic sanit pan-amer 29 397 Tecnica de floculación en portaobjetos de VDRL prueba de floculación en tubo de VDRL prueba de VDRL para líquido cefalorraquídeo Bol Ofic sanit pan-amer 29 509 THOME J V Modificaciones que deben hacerse a las actividades educativas antivenereas de acuerdo con los progresos registrados en su terapéutica con el uso de los antibióticos Bol Ofic sanit pan-amer 29 945 GOODEN DR Influencia de un programa profiláctico penicilinico en la incidencia de las enfermedades venéreas Bol Ofic sanit pan amer 39 1051 1951 SAMAME G Profilaxıs sistémica antivenerea informe preliminar sobre el programa de Tijuana BC Bol Ofic sanit pan-amer 30 42 CUTLER JC & STOUT G Problemas serológicos en Centro América Bol Ofic sanit pan-amer 30 321 Control o erradicación de las enfermedades venéreas Bol Ofic sanit pan-amer 31 169 (Editorial) REIN CR Problemas en el serodiagnóstico de la sífilis Bol Ofic sanıf pan-amer 31 105 KITCHEN DE Penicilinoterapia moderna desenvolvimento eficacia reacciones Bol Ofic sant pan-amer 31 118 BREWER FA Los nuevos antibióticos en el tratamiento de las enfermedades venéreas Bol Ofic sami pan amer 31 127 SANCHEZ PEREZ R Epidemiologia de las enfermedades venéreas Bol Ofic sanu pan-amer 31 132 STOUT GW & REYNARD R Primera encuesta serológica centroamericana Bol Ofic sanit pan amer 31 141 SAMAME G Organización de una división de control de las enfermedades venereas Bol Ofic sanit pan-amer 31 131 1952 SAMAME G Programas de control de las enfermedades venéreas de la Oficina Sanitaria Panamericana Oficina Regional de la Organización Mundial de la Salud Bol Ofic sanit pan-amer 32 37 STOUT G GUZMAN M & SCRIMSHAW NS Reacciones serológicas para sífilis presuntamente positivas falsas en la America Central distribución Bol Ofic sanit pan-amer 32 206 Bol Ofic sanif pan-amer 32 521 I Incidencia y 1 76ج - ·WHO publications may be obtu ed by rajmert is kaal FETI, directly or through a books. Ikt (rom the follours agars YORSAY ** Grus me #4 L Axt Ozo ARGENTINA Editorial Soda, SA Calle Abstra 80 Bora AD AUSTRALIA HA. Coldird po to 255Coorpe Surpat STORET AUSTRIA B Werstort Wetplatz 1 Sultana Gerold & Co 1 Gruben JL YA FRANCE Maar trots 120 4 Sucentas Pus CERMLY Ert & E Harta BM Brun * L. Segre Geront -9 COLO AR Hon MAPPUNTS A 47 WA PORTIT IL La I 11 In A ** STID FAWY XI ZDADE GREECE Lorux focerum Letras BELGIAN COCO du COOL Librairie course An SWITZERLAND 12 m dos Artists kert LOTOLDVILLE ILAM Ma en BELGIL" WA Curri KA O dal & Lite estu po 11- 1 rue de St More Paru-XT SYRIA INDIA that BRAZIL Octs Arct & Secry Co. DRO Livraria Arte Say Catua fomu 341 Nr DO TILAILAND RIO DE JANTO DY tw INDONESIA 9 CM CANADI NY 116.CT Dor & The Ryan ham Das Nastan 3 27 Qanca Surts Wak DIABAE A TORONTO, Ozzano INITY Parlega 127LAND Land it 3112 » Posters The Seatinot MILLAL H PLN CHILE ISRAEL Lయణండు Pana LYOK OF SOUTILATRICA Hatut Co Merced 146 thea Sur Sert Vals vro SANTIAGO 2 w ar com he COSTA RICA ITALY T do Mar Farid Kit Mania LIVED INCH Adado 1313 Como Lost 3 HMT ( SAN kast 1 VOA СЕВА LEBANON La Cues da Lerare le Rent Stores WD STAITS OF Ray 43 AVLEKA HA ANA LLTEVIPOLRG Casamu twWET DEVARE Locuries Scted Isterix Eine Ward, Ltd rue Gatos 0 1 Nacide LIDOL Xrt Yat TKY CUP DRAGON STEXICO CRLCLAY - PCYPT La hau LES Matra Den Lord Linkit Robo Euca Okoard Etus ΤΕτα Dars 165 ta D7 Saarts APS a Cory 3 D 11 * 12- 13) dece Was Harm Cano MEDIERLANDS NLAND NY Mario No Alueen lacn . Brkadd a tesco YLCOSLAV14 Drum Peluxe Kate: 2 Lange Yoorboat Tar Huss Tanroe 1 ·El ácido ascórbico riboflavina fosfatasa alcalina carotina y vitaminas A y E en el suero sanguineo Boletin de la Oficina Sanitaria Panamericana 1949 WRIGHT RD & NICHOLSON FP Treatment as a factor in the control of the venereal diseases Bol Ofic sanit par-amer 28 462 COUTTS WE Organización de la lucha antivenerea bases principales en que actualmente debe apoyarse una campaña Bol Ofic sanit pan-amer 28 545 1950 ARNOLD RC & MAKONEY JF Función de los antigenos de cardiolipina en la serologia de la sffilas Bol Ofic sanit pan-amer 29 397 Técnica de floculación en portaobjetos de VDRL prueba de floculación en tubo de VDRL prueba de VDRL para líquido cefalorraquídeo Bol Ofic sanıt pan amer 29 509 THOME J V Modificaciones que deben hacerse a las actividades educativas antivenéreas de acuerdo con los progresos registrados en su terapéutica con el uso de los antibióticos Bol Ofic sanut pan-amer 29 945 GOODEN DR Influencia de un programa profiláctico penicilínico en la incidencia de las enfermedades venéreas Bol Ofic sanit pan-amer 39 1051 1951 SAMAM G Profilaus sistémica antivenérea informe preliminar sobre el programa de Tijuana BC Bol Ofic samt pan-amer 30 42 CUTLER JC & STOUT G Problemas serológicos en Centro America Bol Ofic sanit pan-amer 30 321 Control o erradicación de las enfermedades venereas Bol Ofic sarut pan-amer 31 169 (Editorial) REIN CR Problemas en el serodiagnóstico de la sífils Bol Ofic sant pan-amer 31 105 KITCHEN DK Penicilinoterapia moderna desenvolvimiento eficacia reacciones Bol Ofic samt pan-amer 31 118 BREWER F A Los nuevos antibióticos en el tratamiento de las enfermedades venéreas Bol Ofic samt pan-amer 31 127 SANCHEZ PEREZ R Epidemiologia de las enfermedades venéreas Bol Ofic sanit pan-amer 31 132 STOUT G W & REYNARD R Primera encuesta erológica centroamericana Bol Ofic sanit pan-amer 31 141 SAMAME G Organización de una división de control de las enfermedades venéreas Bol Ofic sanit pan-amer 31 151 1952 SAMAME G Programas de control de las enfermedades vepéreas de la Oficina Santana Panamericana, Oficina Regional de la Organización Mundial de la Salud STOUT G GUZMAN M & SCRIMSHAW NS Reacciones serológicas para sifilis presuntamente positivas falsas en la Amenica Central i Incidencia y Bol Ofic sanit pan-amer 32 521 t 76 다 ·1951 Symposia on syphils Chron Blu Hlth Org 59 Anti Venereal Disease Commission for Rhine River Area Cardiolipin antigens Chron WH Hih Org 5 265 Chron II Hlth Org 5 72 1952 Venereal-disease-control demonstration in India Chron Filth Org 6 90 First International Sypiposium on Yaws Control Chron Ild Hith Org 6 253 Mass treatment of syphilis in an Indian province Chron 11 ld Hlth Org 6 66 The International Treponematosis Laboratory Center Chron Wyld Filih Org 6 290 A rapid method for the serodiagnosis of syphilis Chron 14 Hlth Org 6 301 1953 Endemic syphilis in Bosnia Chron 14 Hlth Org 74 Venereal-disease-control demonstration in Egypt Chron Wld Hlth Org 7 142 Venereal infections and treponematoses Chron Ild Hlth Org 7 147 Report of the study group on syphilis at the Sixth World Health Assembly Chron Bld Ilth Org 7 203 ·GRIN EI Epidemiology and control of endemic syphilis report on a mass treatment campaign in Bosnia (World Health Organı ation Monograph Series No 11 also published in Bull wld Hlth Org 1952 7 1) WORLD HEALTH ORGANIZATION First International Symposium on Yaws Control (I'orld Health Organi anon Monograph Series No 15 also published in Bull WVld Hith Org 1953 8 7 390) Reports of Experts and Study Groups Expert Committee on Venereal Infections and Treponematoses First Report (Official Records of the World Health Organi afton 1948 8 60) Second Report (Official Records of the World Health Organi alion 1919 15 18) Third Report (u orld Health Organi ation Technical Report Series 1950 13) Fourth Report (IVorld Health Organi afton Technical Report Series 1953 63) Expert Committee on Venereal Infections and Treponematoses Subcommittee on Serology and Laboratory Aspects First Report (1 orld Health Organ! ation Technical Report Series 1950 14) Second Report (Il orld Health Organt ation Technical Report Series 1951 33) Venereal disease control in the USA report of the WHO Syphilis Study Commission (World Health Organ, anon Technical Report Series 1950 15) Special Publications International List of Venereal Disease Treatment Centres at Ports Personal Booklet (issued to seamen for recording treatment of venereal disease at ports) Chronicle of the World Health Organization 19:48 Venereal diseases an international problem Chron Bld Hith Org 2 15 New International effort against venereal diseases Chron 3d Hlth Org 2 267 1949 Serology of syphilis Chron Hd Hith Org 3 14 Penicillin in venereal diseases Chron #ld Hlth Org 3 15 Venereal-disease control in Poland Chron Wyld Hlth Org 3 29 Venereal diseases in Ethiopia. Chron Ild Hlth Org 3 83 Venereal disease in Germany Chron 3d Hlth Org 3 111 Venereal-disease control among Rhine River boatmen Chron Wyld Alth Org 3 117 Penicillin treatment of syphilis Chron d Hlth Org 3 285 1950 New developments in venereal-disease control Chron Bld Hlth Org 4 35 Serology of syphilis Chron IYU Hith Org 4 41 Venereal-disease control in the USA Chron 114 Hirh Org 4. 67 Laternational conference on the serodiagnosis of syphilis Chron Hd Hlth Org 4 150 Lymphogranuloma venereum Chron WW Hlth Org 4 345 Serology of syphilis Chron Yld Hith Org 4 367 78 ·1951 Symposia on syphilis Chron I Hilch Org 5 9 Anti Venereal Disease Commission for Rhine River Area Cardiolipin antigens Chron FH Hlth Org 5 265 Chron Ild Hlth Org 5 72 1952 Venereal-discase-control demonstration in India Chron BW Hlth Org 6 90 First International Symposium on Yaws Control Chron Ild #lth Org 6 253 Mass treatment of syphilis in an Indian province Chron Blu Hlth Org 6 266 The International Treponematosis Laboratory Center Chrom 13 Id Hlth Org 6 290 A rapid method for the serodiagnosis of syphilis Chron Id Hlth Org 6 301 1953 Endemic syphulis in Bosnia. Chron Vid Hlth Org 7 4 Venereal-disease-control demonstration in Egypt. Chron 3514 Hoch Org 7 142 Venereal infections and treponematoses Chron #ld filth Org 7 147 Report of the study group on syphilis at the Sixth World Health Assembly Chron II Hlih Org 7 203 ·WORLD HEALTH ORGANIZATION MONOGRAPH SERIES No 11 EPIDEMIOLOGY AND CONTROL OF ENDEMIC SYPHILIS Report on a Mass-Treatment Campaign in Bosnia EI GRIN The natural course of endemic syphilis including its epidemiological clinical laboratory and other aspects has not been adequately described in existing literature This study represents an important contnbution to the limited knowledge on the subject The environmental factors and their influence on the perpetuation of the infection as an endemic disease and the course of the disease over decades are discussed and onginal theories and new considerations are advanced explaining its behaviour in a primitive cavironment A description is given of the different stages of the treatment campaign in Bosnia in which more than 33 000 cases were treated with peru cillin and promising results obtained The volume is profusely illustrated with maps drawings and photographs English edition only 1953 93 pages 43 figures 51 $100 Sw fr 4 -- No IS FIRST INTERNATIONAL SYMPOSIUM ON YAWS CO ROL A collection of papers presented at the International Symposium on Yaws Contro! held in Bangkok ia March 1952 is published here ja book form They deal with the use of antibiotics in the treatment of yaws the epide miology of the disease and the modern control methods including the prob lems of organizing eradication campaigns The symposium will be of interest to renereologists to all those concerned with the use of antibioti's and to persons responsible for planning or carrying out mass treatment or control campaigns Mixed language edition English and French 1953 second impression 1953 iv +418 pages 32 plates 26 figures 83 tables 22/6 $450 Sw fr 18 - ·WHO publications may be obtained by payment in local currency directly or through a bookseller from the following agents ARGENTINA Alorlal Sudama fauna S.A Cutie Astria 300 BUEYO AND AUSTRALIA HA Goddard Pty Lt 2554 Georte Street SYDNEY AUSTRIA BWctatori agplat 4 SALTO Gerold & Co I Griben 31 VERY 1 BELGIAN CONCO Libralne pegolare 12 da Arialeurs LEOPOLDTILL NORWAY 5 ha Gruodt Tun Forlat Kr Abraft 74 OSLO PHILIPPINES Alomart 749 Rizal Arenge MANILA PORTLGAL Lyr Tla Rodrigues 1 B6 Rua A ma LIXON SWEDEN Aktiebolaret CE Fritza K KH boltanucl Fredsplan 2 STOCKHOLM 16 SWITZERLAND Medlzinischer Verlag Il nt H ber M I are 9 Bank BELGIUM Once International de Lloratele 144 rue de l'Hochde-Monnaie PUSUL BRAZIL Lyrarla Ad Gina Posial 1291 ROD JANEIR DF CANADA The Ryerno Preta 299 Queen Street West TONTO Ontario Periodica 5112 P placa MONTIE 14 CHILE Edmonda Pizart Merced 146 SANTIAGO COSTA RICA Trefor Hermanos Apartad 1313 SAN Jost CUBA La Casa Bels Kezze de Smedt O Relly 455 HA ANA DENMARK Ejnar Munk gaard, Ltd Nørregade 6 COPENHAGEN EGYPT Librule La Renaissance a Ezyp 9 Sharia Adly Pasha cano FINLAND Akateemitien Kujata PDS Kekkatu 2 HOTEL FRANCE Mson & Co Editeur 1.0 bd Salnt-Germala PARA GERVLANY Evert & Meurer Ila pietraxe 101 BESCHORDEO WE Surbach Ctreongtrase 25- COLOG Alex Flora Spiercizasy 9 WETLADEN GREECE Librairie Internati ale Eleftheroudakis Place de la Constitution ATHENS HAITI Max Boucherea Librairie A la Caravelle Bolte posta] 111 B POT U-PENC INDIA Oxford Book & Stationery Co Scindia llouse Now DELI INDONESIA NY OCT D&Co Djalis: Nusantara 22 DAKA A IRELAND The Stationery Once DUDLIN ISRAEL Helttect & c > N nam Sau tren JERUSALDX ITALY Edison Mineta Medid Corso B ama te 83-83 TUIN LEBANOV Lib alric Un cruell BURUT LUXEMBOURG Librairie J Schommet Place Guillaum LUXOROURO MEXICO La Prensa Medica Mexicana Edici nea Cleotibaas Durang 145 MEXIOO CT 7 DF NETHERLANDS NY Martion Nuhor Bockla del co Uitgevca Maatschappij Laoge Voorhout 9 TE HOUS SYRIA Librairie Volveracit D MASCUS THAILAND PY mun Mit Led 35-39 CD krawat Rond Wat uk BANG TURKEY Librairie HA hette 66 de lidt perda cc IST NBUL UNIOVOF SOUTH AFRICA V Subalt Boots (Pty) Bookscins and Stationers PTO LA UNITED KINGDOM HM Stati sery One PO Bo 569 LONDON SE 1 UNITED STATES OF AMERICA Co! mbi University Press In erna cal Documents Service 2960 Scoafws NEW YORK 27 NY URUGUAY Oicina de Representació de Editoriales Prof Héctor DE 18 de Juli 1333 P do Diaz MONTEVID PO YUGOSLAVIA Dave Preduzece Jugosi ens Kolka Tersaje 27/01 BOLGLAD Orders may also be addressed to Sales Section Palais des Nations Genetz, Switzerland, but must be paid for in one of the currencies a which pries are quoted below ·WORLD HEALTH ORGANIZATION MONOGRAPH SERIES No 11 EPIDEMIOLOGY AND CONTROL OF ENDEMIC SYPHILIS Report on a Mass-Treatment Campaigu in Bosnia EI GRIN The natural course of endemic syphilis 1o luding its epidemiological clinical laboratory and other aspects has not been adequately described in existing literature This study represents an important contribution to the limited knowledge on the subject The environmental factors and their influence on the perpetuation of the infection as an endemic disease and the course of the disease over decades are discussed and original theories and new considerations are advanced explaining its behaviour in a primitive environment A description is given of the different stages of the treatment campaign, ia Bosnia in which more than 35 000 cases were treated with peni cillin and promisiog results obtained The volume is profusely Mustrated with maps drawings aod photographs English edition only 1953 93 pages 43 ngures 5/ $100 Sw fr 4 - No 15 FIRST INTERNATIONAL SYMPOSIUM ON YAWS CONTROL A collection of papers presented at the International Symposium on Yaws Control held in Bangkok in March 1952 is published here in book form They deal with the use of antibiotics in the treatment of yaus the epide mology of the disease and the modern control methods including the pros lems of organizing eradication campaigns The symposium will be of interest to renereologists to all those concerned with the use of antibiotics and to persons responsible for planning or carrying out mass t eatment or control campaigns Mixed language edition English and French 1953 second impression 1953 1+ 418 pages 32 plates 26 figures 83 tables 22/6 $4 50 Sw fr 18 - ·YHO publicuous may be obtained by payment in local currency directly or through a bookselles, from the following agerts ARGENTINA FRANCE MORNA! 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