wffio5 WPR/VDrI48
THE FIRST WORLD HEALTH 01lGANIZATION
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/
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VENEREAL mSFASE CONTROL SEMINAR OF THE WESTERN PACIFIC REaroN
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Tokyo, Japan
17-29 March 1958
.. FDiAL REIORl'
H6a1,b Jrgan1zation Western Pacific Regional Office Manila, Philippines Jul.y",
ft~rld
1959
CONl'ENTS Page 5
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1.
I l'll'ROlJ1l: TION VENEREAL 2.1 2.2
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•• •• • • r
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... .;
2.
DI~EASFS
IN i'IESTERN PACIFIC REGION OF WID
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6 6 6 10 10 10
Introduction
• • • • • • • •
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• • • • • • • diseases • •
• • • • • • • •
Trends in prevalence of
ven~roa1
3.
SYPHILIS 3.1
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Extent of the problem 3.1.1 3.1.2 3.1.3 3.1.4 3.1.5 All syphilis
.s. ,Ir' ,-
... 3.2
• • • • • • Early syphilis • • • • • Late syphilis • • • • • • Erxiemic syphilis • • • • Congenital syphilis • • •
13 14 15
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15
Diagnosis of syphilis • • 3.2.1 Introduction
• • • • • • • • • • • • • •
16 16 16 17 19 19
.. ... 3.3
3.2.2 3.2.3
• • • • • • • • • • • • • • • • Darkfield examinations • • • • • • • • • • • Serum tests • • • • • • • • • • • • • • • • •
Treatment of syphilis • • • 3.3.1 3.3.2 Early syphilis
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Late syphilis • • •
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21 21 21
11
3.4
ether aspects ••
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4.
GOll>RROOEA 4.1 4.2
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Extent of the problem •
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22
Diagnosis of gonorrhoea •
22
~PR/VTJr /48
page 2
CONTENTS (Continued)
4.
GOOORRHOEA (cont 1d.) •
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• • • • • •
4.3
TreatlIlflnt of gonorrhoea-
·• • ·• • · · · • · , • • • • 0
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• • 21 23
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... ~
4.3.1 4.3.2
• • • • • • • • • • • • • • • 23 Failures to penicillin • • • • • • • • • • • • 24 General (a) (b) (c) clinical aspects laboratory as~ccts
·
25 future COIlS idera tiOIlS • • • • • • • • • • 25
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• • • • • • • • • • • • • • • • • • • •
24
4.4
other items
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• • 'Z1 2B
5.
OON-GONOCOCCAL UREThRITIS
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·
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...
5.1 5.2
Extent of the problem Etiology
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28 2$
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6.
·•• • • •• •• •• • • ••••• • 5.3 Treatment • • • • • ······• ··• • • • • • • • OTHER VENEREAL DISEASES ··• • • • • • • • • • • • • • • • 6.1 Chancroid • • • • • • • • • • • • • • • • • • • • • · 6.1.1 Extent of the pr.-oblem • • • • • • • • • • • · 6.1.2 Diagnosis • • • ··• • • ·• • • • • • • · · 6.1.3 Treatment • • ·• • ·• ·• • • • • • • • • • 6.2
30 30
30 30
....
31 32
Lymphogranuloma venereum • • • • • • • • • • • • • • • 32 Granuloma inguinale other conditions •
6.3 6.4 7.
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0' .' •
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32
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• • 33
REACTION) TO PENICILLIN
7.1 7.2
Nature and extent
·• • · •
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• • • 33
• • • • • • • • • • 33
Prevention of penicillin reactions • •
·•
• • • • •
• 35
WPR/VDT/48 page 3 COOTENTS (Continued) Page
8. "-
VENEn.EAL DISEASE PREVENTION AND CONTroL •
8.1 8.2
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8.3
• • 8.4
···• · • ·• • • Introduction • • • • • • • • • • • • • • • • • ·• •• Notification of venereal diseases ·• •·• • • • • • • Case-finding ·• • ··• • • • • • • ·• • • • • • • • 8.3.1 Contact traci.'1g • • • • • • • • • • • • • • • · 8.3.2 Examination of special groups • ·• • •• • • l1ari time aspects of venereal disease control • • ·• • 8.4.1 Introduction • , • • • • · • • • • • • • • . 8.4.2 Brussels Agreement • • • • • • • • · · • • • · 8.4.3 Prevention of venereal disease in seamen 0
36 36 37 38
38 38 39
39 39 40
• • •
.Jf,
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8.5
Military aspects of venereal disease control HElulth
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41 41 43 43 43 44
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a.6 8.7 8.8
education
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AvaUabUity of treatment • •
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Prostitution and venereal diseases
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..... .....
8.8.1 8.8.2 8.8.3 8.8.4 8.8.5 8.8.6
Toleration of prostitution
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•
• •
Venereal disoase in prostitutes • • • • • • • • Proportion of venereal diseases caught from prostitutes • • • • • • • • • • • • Emphasis placed on venereal-disease control in a country where brothels have been abolished •
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46 46
Routine medical examination of prostitutes
•
•
48 48
Prophylaxis of venereal disease in prostitutes using antibiotics • • • • • • • • • • • • • •
9. 10.
.suMMARY AND CONCLUSION S • • • • • • • • • • • • • • • • •
• •
51 58
REFEhENCES • • • • • • • • • • • • • • • • • • • • • • • • •
liffi. /VDT/48 page 4 C~TENTS
(Continued)
AWEX I.
Report of -loJorking Group No. 1 on methods for measuring the prevalence and/or incidence of venereal diseases with particUlar reference to the applicability of such methods to the ;J£f:tem Pacific Region of WHO • • • • • Minimal therapy for the individual patient with venereal syphilis • • • • • • • • • • • • • • •
62 70
II.
• • •
III.
Report of Horking Group No. 2 on reactions to penicillin ~
LI.ST OF TABLES
. . . .. . . . . . . . . . . . . . . . . . . . . . . .. . . • • • • • • • • • • • • • • • • • • • •
73 79 88
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LIST OF FIGURES • •
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(
WP"ft/VDT/48 page 5
1.
INTRODUCTION The first internatiooal venereal disease cootrol seminar sponsored by
the Western Pacific Regional Office of the World Health Organization, and for which the host Government was Japan, took place at the Gakushi-Kaikan (Alumni Club of the National Universities of Japan) in Tokyo from 17-29 March 1958. There were 20 participants from 11 countries or territories within the Region. The meeting was opened by the Honourable Hinister of Health and lielfare, 11r. Kenzo Horiki,
who,
through Hr. Saita, Chief LiaisQ'l Officer, International
Affairs, Ministry of Health and Welfare, emphasized the importance of this seminar as the first of its kind to be held in the Regioo. a
Dr. I. C. Fang, Regional Director of the western Pacific Region of WHO, stated that the objective of the Organization was the attainment by all peoples of the highest possible level of health, and indicated that venereal diseases had for loog remained a cQ'lsiderable problem in the ,Jestern Pacific Region where cooditioos favouring their spread still persisted. His Excellency the Governor of Tokyo, represented by his deputy, His Excellency T. Hagiwara, indicated that the problem of venereal diseases was particularly to the forefront at the present time and that the Host Government was awaiting the deliberations of the seminar with much interest. Professor Akira Takahashi, President of the Japanese Venereal Disease Prevention Association, expressed satisfaction that venereal diseases in Japan were gradually decreasing but expressed dismay that the concern of the public was also decrea~ing
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and that there was a tendency to reduce the He stated that it was the
budget for national venereal disease expenditure.
hope of his organization that .iliO would continue to lead the way in this field in their work towards the elimination of these diseases.
Dr. M. Yamaguchi, Director of Public Health, Ministry of Health and Welfare, was elected President and Dr. H.C, Johnston (~ustralia) and Dr. N. H. Phiem (Viet Nam) were elected Vice-Presidents. In his presidential address, Dr. Yamaguchi rearfinned that the holding of the seminar in Japan was timely and appealed for a wider outlook on venereal disease control than the mere management of venereal disease in prostitutes. A drafting committee consisting of Dr. L. H. Ram (Singapore: Chainll6Il), Dr. L. Begoo (French Polynesia), Dr. T. L. Yusay (Philippines), Dr. T.H. ~ong (Ghina-Taiwan) and Dr. R. R. IUllcox (dHO Venereal Disease Consultant:Secretary)
JP'r'o./VDT/48 page 6 was elected to draft the seminar's report, which should contain a summary embodying the conclusi~s reached, and prepared in such a way that it might be of assistance to health administrations in planning venereal disease control programmes in the region in the future. 2. VENEttEAL DI::;EASE.:; IN THE iE..>TiliN PA,L'IC REGION OF JHO
2.1 Introduction The~1HO.'1estem
Pacific Region covers a wide area stretching almost from It includes many isFIG. 1
the .arctic to the f.ntuI.'Ctic and across the Pacific Ocean. lands, archipelagos and peninsulas.
It embraces great varieties of people
•
with many different languages, customs, religions, economic, political, military and geographical problems, and cultural backgrounds which to some extent have influenced not only the attitude to the problems of venereal disease control in different areas, but also the problems themselves. Examples of these mOdifying factors include: the many scattered islands of the Philippines and of French Polynesia; 9 a multiplicity of frontiers as in l Laos,7 and increasing populations (as in Singupore where the population in4 creased b.Y 24.2% from 1950-1956 and in Hong Kong where it increased b.Y 39% in 10 years). Moreover, in many parts of the East, relatively large numbers Hong Kong 4 for example has a of the poorer classes live on small boats.
permanent sampan population estimated at 120 000 and similar situations pertain in Japan and other countries. Nili tary activity and social upheaval has contributed to venereal disease problems particularly in Cambodia,ll China (Taiwanl,36 . 12 The segregation of women and arranged Japan, 24 Korea, 6 Laos, 7 and Singapore. marriages with the subsequent recourse to prostitutes by young men were infiuencing factors in Cambodiall as was the view widely held in Japan that it was illllloral to have extramarital intercourse with anyone but a prostitute.17 2.2 Trends in prevalence of venereal diseases Total venereal disease rates based on clinical incidence varied. in 1956 (Fig.2). In
Jap~4
the rate had fallen from 5.2 cases per 1000 population in 1951 to 1.6 per 1000 Even in the Self-Defence Forces the decline had been from 38.9 FIG. 2
per 1000 men in 1951 to B.3 per 1000 in 1956. A similar marked decline had been l noted in Singapore: 8.7 per 1000 population in 1950 to only 4 per 1000 in 1956.
iPR/VDT/48 page 7
FIG. 3 Total syphilis rates had likewise declined in most areas, including Australia,J (Fig.3) Hong Kong,4 Japan,5,20,2J,24 (Fig. 2) PhilipPineSI~ (Fig.4) Singapore; and Viet Nam. 10 In Japan,5 for example, the case rate for
syphilis had fallen from 189.7 per 100 000 in 1947 to 26.9 in 1956. FIG. 4
In New
South iJales, Australia3 :in 1956 there I.ere 6.88 cases per 100 000 compared with 7.45 in 1954. A very high rate of 320 per 100 000 was reported in a
small group of 25 000 soldiers :in Laos.
7
The fall affected
ear~ syphilis
:in
.....
particular and the disease, apart from small local "kickbacks", continued to decline throughout the regj.on. With modern treatments, death rates from syphilis had likewise fallen. 5 ,23 (Fig. 5)
•
FIG. 5 Group serum tests for syphilis in Japan in 1956 gave seropositivity rates 23 of 3.3 to 3.8% shOwing a decline from 4.5% :in 1954. Reported seropositivity 1 rates :in blood donors were 9.7 to 12.6% in Taiwan~ (1954) 2.6:.> in Singapore 2 4 (a decline from '1.0% in 1949) and 0.13% in Hong Kong. In Taiwan school teachers' seropositivity was 6.0,;, while in the Philippines3'J seropositivity rates between 2.08~
and 5.01% were obtained in premarital tests, and 4.36% to Seropositi-
5.39% in tests on city employees depending on the procedures used.
vity rates in expectant mothers :in 1956 varied from 15:0 in Cambodiall to only 1.41~ in Singapore1 which figure had been 5.4~ in 1951 (see under syphilis). In 1956, the incidence of infantile syphilis was 13 per 100 000 in
•
4 l Singapore and the infantile mortality in Hong Kong was 7.24 per 100 000 while in 1951 it had been 27 .74 per 100 000 population. to syphilis. The overall picture for syphilis, with a few exceptions such as in Camll bodia and LaOs,? therefore indicated a striking improvement in recent years. The situation as regards gonorrhoea was more disquieting. Although in In CambOdia,ll how-
ever, much of the 55% infant mortality rate reported was considered as due
...
most countries there had been a fall since World iiar II (e.g. from 272.4 per 100 000 population in 194? to 129.5 per 100 000 :in 1956 in Japan5) (see Fig.2) the position in many countries had become static or there had been an increase again in recent years. Taiwan and Viet Nam. 10 8uch pertained in many countries outside of the region and also in Australia,3 (Fig.3) Hong Kong,4 Singapore,l the Philippines, (Fig. 7)
WPR/VDT/48 page 8 Current gonorrhoea rate., varied from 45.39 per 100 000 population in 1956 in New South liales, Australia,3 129.5 per 100 000 in the same year among civilians in Japan 5 (580 per 100 000 in the military24) to as much as 4000 per 100 000 in a military group of 25 000 men in Laos7 in 1955. Moreover, although gonorrhoea was accompanied by few complications in adulti,J,lO there was considerable evidence from many countries that repository penicillins used in higher doses f,c;r its treatment than formerly were being less successful. 3,8,10,18,40,41,43 Non-gonococcal urethritis was also a problem in sane areas and was even 8 increasing (e.g. the Philippines ). In some countries, e.g. in parts of lO Australia, 3 Korea,32 and in Viet ~ am it was more COIlllllon than gonorrhoea in several of the principal venereal disease clinics. Horeover, its etiology 2 was still largely obscure ?,35 and its treatment with antibiotics often ? expensive. In some areas, e.g. Laos, no attempt was made to differentiate ~ non-gonococcal urethritis from gonorrhoea. Of the other venereal diseases, chancroid was considered to be the most important, especially as it frequently confused the diagnosis of syphilis. 5 In many countries, (e.g. Japan where in 1956 there were 3.4 cases per 100 000 population, as compared with 52.3 in 1947, and in Viet Nam;O Taiwan (Ohina), Hong Kong,4 Japan,5,24 Korea and the Philippines,8) there was a declining ll incidence although some 3155 cases were seen in Camoodia in 1956, and in Laos? there were 350 cases of chancroid 'among 25 000 soldiers in 1955. In 4 l marw areas, e. g. China (Taiwan), Laos,? Hong Kong, and Singapore, chancroid was considerably more COlllllon than primary syphilis. LYmPhogranuloma venereum existed in most countries of the region. In 4 Cambodiall some 50? cases were reported in 1956. In Hong Kong the clinic case rate in 1956 was 5.7 per 100 000 population. ever, it did not represent a public health problem. rare. had been encountered between 1950-1956. Generally speaking, howGranuloma inguinale was l In Japan5 in 1956 there had been no cases and in Singapore no cases In Australia] in 1956 only three c'
..
.
cases w.ere reported from the Northern Terri tory. Venereal disease statistics 'tere mainly based on the number of ne't cases attending the governmental clinics and dispensaries. The returns were therefore infiuenced by the accuracy of diagnosis (especially in cases of genital ulcer), conscientiousness in reporting the proportion of venereal diseases
.iiR/VDi/48 {lage 9
treated outside of the clinics and the adequacy of existing facilities in relation to the total venereal disease problem as well as to other factors. 16 For example, in 1955 in Korea more than JOO times the number of venereal disease cases were treated than in 1947 when the vt'aereal disease programme was first initiated. In French Polynesia, 9 only f:IJ cases of gonorrhoea were treated in 1956, a figure considered to be "well below reality". It was recognized that were notification procedures were well established the appraisal of trends of reported cases of venereal disease over a nUlllber of years could 4 provide 'useful information concerning incidence. Other indices for assessing the extent of the problem included the preSUch
valence of sero-reactivity in pregnant women and in certain occupational and other population groups (armed forces, city employees, seafarers, etc.). data were influenced by the quality type and nUlllber of serwn tests used, the age-groups of the population tested, the presence of an endemic treponematosis (e.g. yaws) in the community, and by selection factors in the material. from primaparae. 1
In
antenatal tests, for exa.nq:lle, multiparae might show different prevalence rates Seropositivity rates in the latter were an important indicaAlso useful were death These again tion of new infections in the population as a whole.
,"
rates from syphilis and neontal mortality rates due to syphilis. were influenced by accuracy of diagnosis and reporting.
.
It was apparent that, for the reasons stated, the data available concerning the nature or extent of venereal diseases in the Region and of trends in prevalence were extremely variable from counu-y to country, and could not strictly be compared. general., The diseases were a greater problem in the towns than in the ' ',' rural areas (e.g.in Australia; CambOdia,ll Laos, 7 and the Philippines 8 ). In however, it was agreed that since the introduction of antibiotic
treatment venereal diaeases had assumed more manageable proportions in some but not all areas of the western Pacific Region. For example, in Japan 5 in 1955, it was estimated from a one-day survey
that more than 8.8 million man-days had been lost for venereal disease treatment and some 720 000 new cases were likely to have been treated during the year. ? In Laos, v.enereal diseases were rare ~ years ago but had now assumed" a certain importance". They were a major public health problem in Viet NamlO and also in Cambodia where
equal or greater than tuberculosis and leprosylO
WPR/VDT/48 1=88e 10 their importance wa" only preceded by malaria. ll facilities and persor~el
l1uch therefore remained to
be done before control could be obtained in some areas particularly where were scarce.
It WAS agreed, in view of wide variations in reporting, that it was desirable to study methods by which the venereal disease situation could be more accurately assessed. been done by means In Japan,S and other countries, valuable work had In Tokyo in 1952, of one-day and other short-term surveys.
it had been
that only 9.6% of cases diagnosed by private practitioners 8 had in fact been reported. 5 ,23 Even in the PhiliPPines with a comprehensive organization it was estimated that only
sho~
50%
of cases were notified.
party was therefore established to study this matter further.
A working a (See ./Innex 1....).
The various venereal diseases will next be considered separately. 3. SYPHILIS
3.1 Extent of the Problem 3.1.1
All Syphilis (a) Introduction l
s,Y,philis as a whole had declined in most areas, e.g. in Australia,3 (Fig.J) Hong Kong,4 and Viet Nam. 10 Japan,5,2J,24 (Fig.2) PhilipPines,8 (Fig.4) Singapore for example, there In hospitals and clinic s in Viet Nam, 10
had been 4957 ClUies in 1951 and only 2892 in 1956. In a clinic in the Philip8 Pines there had been only 96 male cases of syphilis in 1956 compared with 725 of gonorrhoea. In Japan,5,20,23,24 the clinic incidence had declined (from 189.7 per 100 000 in 1947 to 146.0 per 100 000 in 1950, 44.5 per 100 000 in 1953 and 26.9 per 100 000 in 1956).5 There was, however, in 1956 an increase 24 3 In New South ·"ales, Australia there were amongst the Self~efence Forces. 7.45 cases per 100 000 population in 1954, which figure. has cases per 100 000 in 1956. declined to 6.88 It was
In six Australian states the notified incidence
was only 5.5 per 100 000 (457 cases in a population of 8 201 846).
.! The working party consisted of Dr. D. R. Thomson (WHO, Tha.land), who was Chairman, Dr. Miyairi (Japan), Dr. H. C. Johnston (Australia), Dr. Yamamoto (JapE.n), Dr. Cha (Korea), Dr. Phi em (Viet Nam), Dr. Frb1iLich (WHO, Taiwan); Dr. Soda (Jap1n), Mr. Fuchiwaki (Japan) and Dr. Huggins also attended. Their report is given in Annex I.
viPft/VDT/48
page II suggested that the wide use and misuse of penicillin over the last 15 years may have acted as a broad prophylactic against T. Sallidum and may have changed
the host / treponeme lalance in favour of the host. (b) Group serum tests ~hilis
4 .
The prevalence of
might be assessed by the mass serum testing Results thus obtained had a number of variables
of special population groups.
(e.g. type and quality of tests used; presence of endemic treponematosis in area; age, education and sexual habits of group tested; etc.) and coul:!. not be strictly compared from cne country to another. (i) General popula tion
In serum testing of unspeCified population groups in Japan, 3.3% of
positive results were obtained in 415 235 persons tested in 1956 as with 4.5% in 558 Y/l perscns tested in 1954.
co~ared
23
In Taiwan, a 7% seropositivity
25 rate was encountered. (ii) Hospital J! tients
. •
Seropositive rates of 19.2,. were reported among patients of health staticns 2 and 18.8% in hospital patients in Tai\ian (1954) (iii) Employment groups In the
School-teachers in Taiwan showed seropositivity rates of 6.0%.2
Philippines, among City enployees, 4.36% positive results were obtained with the Kahn test, 5.3% with the Kolmer and 5.2% with the VDRL tests. 33 (iv) Premarital tests
Premarital tests served the useful function of finding syphilis in a sexually Seropositivity rates might vary according to the tests used. 33 a 5.01% positivity rate was found with the Kolmer tests, the PhilipPines active group. In
2.62% with the Kahn test and 2.08% with the VDRL test. (v) Blood donors ~hilis
3erum testing of blood donors for lation at large.
was relatively simple to arrange
and served as a lUeful index of the prevalence of syphilis in the general popu-
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WPR/VDT/48 page 12 In ':'ingapore, l in 1956, of 4979 predaninantlyAsian blood donors only &0or syp hil" In 1949 the .L~gure" &0" 131 (2. 6) % had positive serum reactions ... ~s. 1 2 was 7%. In Taiwan seroposi tivi ty rate s in blood donor s ranged from 9.7'/0 to 12.6~(1954). Among 2651 European donors in Hong Kong 4 in 1957 only 2 positive reactors were found, whereas in 1954 seven positive reactors had been noted in 2566 persons tested. (vI) Prisoners Jrl
Serum tests in prisoners indicated the situation in a group which was particularly prone to venereal disease and much higher seropositive rates were to be expected than in the remaining population. in the rates through the years was less striking. in More(ver, improvementIn a small group tested
.,
~gaporel 28% were seroreactive.
In a large group tested in Hong Kong4
there were 27.83% of positive reactions in 1954-1955, 24.8% in 1955-1956 and 21.02% in 3135 tested in 1956-1957. (vii) Expectant mothers
The serum testing for syphilis of expectant mothers was useful not only because cases of syphilis ~ere
.
,
revealed and further contact tracing in the
family was undertaken, permitting the prevention of congenital syphilis with the proper usage of penicillin, but also because it provided an index of the
prevalence of syphilis in a young and sexually active but otherwise generally normal group. Varied seropositivity rates were reported in the region ranging from 15% ll 2 in Cambodia to 5.0%25 -7.3% in Taiwan and 3.5% in a large series of 24 359 4 tested during 1957 in Hong Kong. Lower figures were reported in Japan45 where positivity rates of 2.6% had been noted in 1954, 2.3% in 1955 and only 21 2.0% in 1956. In the Philippines during the years 1952-1956 11 683 women had been examined and there were 1943 sero-reactors (1.73%) of which a number were shown not to have syphilis and manifested serum changes due to yaws. Only in 85? instances (O.??%) were the changes considered to have been due to syphilis. In this series, there were only 11 cases of early symptomatiC
.., -
syphilis, the majority being cases of ]a te syphilis. It was also &hown in the Philippines33 that seropositivity rates varied according to the test used. In a series of studies 2.6% of positiVi.tY·rates were obtained with the Kal.n test, 4.57% with the Kolmer and only 1.94% when the VDhL test was employed.
Low figures (1.4% in 1956) were also reported tion of latent cases) than in primiparae. index of the prevalence of early syphilis. in 1956 from 5.4% in 1951.
!l"QlIl
Singapore..
In previous
years higher rates had been noted in mult;i.parae (doubtless from thQ aooumulaThe rate in the latter was a better The total rate had fallen to 1.4%
(Table I). TABLE. I
L:OVer the period 1951-1956 the rates showed 2.8% positive in Chinese, 4.6% ... positive in Malaysians, 4.0% positive in Indians and 4.3% positive in other racesJ (viii) Seamen
Seropositivity rates were higher in sailors than in the population at large. In Japan13 in 1955 an 8.1% seropositivity rate was found in seamen compared with 2.5% in the general population. (c) Mortality from a.iphilis
other indices to calculating the trends in prevalence of syphilis included
....
the death rate from syphilis. In Table II the fall in the death rate due to syphilis in Japan is given. 5 ,23 The figures also indicate the fall in the number of patients treated. (Table II). TABLE. II
•
Early syphilis In nearly all areas of the western Pacific Region, e.g. Japan,
5 the in-
cidence of early syphilis, as adjudged by clinic and dispensary returns, was declining although there had been a small kick-back in Singapore in 1957 in spite of an increase in VD expenditure.
•
4 1 Clinic admi.ssion rtates for early syphilis in Singapore and Hong Kong had been 30 per 100 000, having in Singapore fallen from 100 pi r 100 000 in 1 4 1950. In Hong Kong whereas there had been 863 cases of primary and secondary syphilis in 1951, the figure had declined to 113 in 1956 and in the fLrst 11 months of 1957 only 23 cases had been seen. In the
Philippines~ early syphilJs In Viet Naml.O
was a negligible problem in Naval and Air Force
bases there and in 1957 there
had been 1194 cases of gonorrhoea and none at all of syphilis.
WPR/VDT/48 page ~
primary syphilis was rare.
In Laos
7 it was often confused with chancroid
and the two diseases were not differentiated although in a.group of 25 000 soldiers in 1955 the syphilis rate was 320 per 100 000. Late syphilis The numbers of cases of late s,yphilis did not necessarily reflect the present incidence of the disease. Complications take some years to develop
and the figures for late syphilis are therefore rela ted to a considerable eXtent to past prevalence. It was noted in a number of areas that in addition It was rspor:tad from some areas..
to early syphilis there had al(lO been a decline in the number of cases of late syphilis, including neurosyphilis. was still due to syphilis. however, that a significant proportion of psychoses in mental hospitals In Cambodia, for example, no less than 30 cases
of s,rphilis had been found in 100 patients hospitalized for mental disease. their admission to the late effects of syphilis. In Japan,5 although there
ll
In a mental hospital in Singaporel·.lO% of male and 7% of female patients owed had been a decrease in the death rates in all other forms of syphilis, an increase in the number of deaths from cardiovascular syphilis had been observed (see Fig. 5). diagnosis. Although clinical late syphilis was reported to haVe become rare in some areas (e.g. Australia3 ) there had been in others, in spite of the general fall in early s,rphilis, a definite increase in latent cases (e.g. in Korea).32 In 4 Hong Kong there had. been only 1251 cases of late (including late la tent) syphilis in 1951 which figure had increased to 2782 in 1956 and t 0
This might have resulted from improved methods of
•
.. •
2496 for the
first 11 months of 1957 when the case-rate per 100 000 population was calculated as 102.3. An increase in Jatent syphilis had also been noted in some
parts of Japan, notably in TOkyo,23 and here as elsewhere sero-reve.rsal 20 follOwing treatment was uncertain. In the data of the Japanese &:IfDefence Forces, in contradistinction to the civilian figures, there has been no striking decrease in the syphilis figures, due presumably to latent cases. Many of the weakly positive serum reactions encountered in serum surveys in 25 Taiwan were considered to be due to old untreated or partially treated 25 syphilis. In a survey in Taiwan it had been noted that tVphilis was 24
b
,;
1-. WPR/VDT/48 I1ge 15 nearq always a..7J1lPtamat.ic and skin lesions had been found in only 1.3% ot 9 149'7 patients. Si.milar experience obtained in French Polynesi.4 where in 1956 only 70 patients were treated out of 1700 sero-reactors. 3.1.4 Endemic syphilis No evidence was forthcoming of any widespread existence of non-venEreally acquired endemic syphilis in Children, although it was considered possible that some cases might be found in Viet Nam and also in French Pol:ynesia where outbreaks of syphilis had been noted in small villages and where seropositivity9 rates of up to 75% had been encountered in groups of' schoolchildren. Yaws, e
another endemic treponematosis, was present in a n'Wllber of countries
ot the
.Region ( e.g. Laos, CambOdia, ~1alaya, the Philippines and the Pacific Islands) and in others the disease was occasionally seen (e.g. Taiwan (China)2 and l Singapore ). The presence of' yaws in an area would often confuse the inter2l pretation of serum reactions for syphilis. 3.1.5 Congenital Syphilis In Phnom-Penh" the capital of Cambodia,ll it was stated that infant mortality Wad as high as 55% and that s,yphilis was responsible for a great part ..... of it. In most areas where statistics were compiled, however, there had been a striking decline in the infantile death rate due to syphilis (e.g. in Hong Kong,4 Table III). TABLE III
•
There was little congenital syphilis in Australia.:3 clinics in 1957 compared with 19 in 1956 and 164 in 1951.
In Hong Kong
4 there
had been only 3 cases of congenital syphilis under one year seen in the VD In Singapore,l the infantile syphilis rate was as low as 0.8 per 100 000 in 1956 compared with 13 per 100 '000 in 1950. In Japan 5 where there had been 37 deaths from congeni-
"
tal syphilis per 100 000 live births in 1950, 11 in 1953 and only 4 in 1956, a 45 similar decline was noted. In Japan only 0.16% of 144 654 foetal deaths in 1956 were due to syphilis compared with 0.77% in 1950 (Table IV). TABLE IV The generally more satisfacto~
situation concerning congenital syphiliS
was considered to have arisen from the routine serum testing of expectant mothers and the treatment of those found to be syphilitic with penicillin. 21
WPR/VDT/48 page 16
Recent f$ropositivity rates in expectant mothers varied from 15% in ll CambOdia to less than 2% in some areas in 1956,e.g. Singaporel and the 2l Philippines (see 3.1.1. (b) (vii). It was a common practice, if the dianosis of syphilis in pregnancy was doubtful, to administer full treatment to 25 the mother. The results of treatment of the mother are so excellent that a healthy baby could almost certainly be expected. 43 (Table V). TABLE V
Serum testing for syphilis of pregnant women was an economical case-
finding tool in areas in which there was little or no ya,ls or other endemic treponematoses to confuse the results. in the western Pacific Not only did it uncover maternal cases It was not universal but also it enable congenital syphilis to be prevented.
Region that all expectant mothers had the advantage
of such serum tests and it was urged strongly that their availability should be extended to the maximum in all maternal and child health centres. A local difficulty has been experienced in Taiwan 2 ,25 as many Taiwanese believe that blood is inherited from their Ancestors and there is a marked resistance to the taking of specimen. of blood. In these circumstances, the cord blood of the
..
child has been tested instead. be employed in the absence of an gooi tal syphilis is low. 3.2 Diagnosis of 5nPhilis Introduction
It was felt that cord blood testing should only ante~atal
clinic service for pre-natal serum
testing and that this procedure should not be used when the incidence of con-
3.2.1
..• •
The importance of the laboratory as the basis of efficient venereal-disease 26 control expecially in the management of syphilis, was stressed. The future advance of venereal-disease control would depend greatly on the streRgthening Research, evaluation and standardization of reagents and methods we);'.: reQuired26,38 and the use of the simple and efficient procedures should be encouraged. 3.2.2 Darkfield examinations of the laboratory.
Laboratory procedures used in the control of syphilis were the darkfield and serum tests (repeated if necessary). best performed Darkfield examinations were often in the clinic and should be done as a routine in all cases of
ilf'R/VDT/48
page 17 genital sore. Expecially was this important in many countries of the Western Pacific' Region where soft and other genital sores in relation to primary sy_ philis were relntively common (see under chancroid). If l'8liance was placed on the clinic al examination alone, not only would cases of syphilis be missed but cases of chancroid or other genital sores in persons wi. th a positive serology due to late latent syphilis or to other treponematoses (e.g. yaws) might be incorrectly classified as failures to peni-
..
cillin treatment when, as was likely in such cases, serological reversal failed to occur follOWing treatment. It was evident that darkfield tests were not being done sufficiently in the region. In many countries they were available only in the larger hospitals and central clinics (e.g. in Korea32 and Taiwan ). were groups together.
2
In others, e.g. in Laos,?
no attempt was made to distinguish syphilis from chancroid and the two diseases
3.2.3 Serum tests Some countries (e.g. Laos,? Cambodial l ) had inadequate laboratory services. There were few well equipped laboratories in Korea.
..
32 Venereal disease control
depended on a sound laboratory26 in which the aim should be to standardize procedures - a technical policy which had been followed by some countries of the iiestern Pacific Region (e.g. Japan)38 for some years. The centralization of laboratory services responsible for the performance of serum tests for syphilis, consistent with efficiency and local conditions, was desirable rather than there should be numerous laboratories performing small numbers of tests. All local serological laboratories should depend on a central reference laboratory at which results could be checked. The need for such ' " tl labora t Or1es was s t resse d( e.g. ~ AUS raia, 3 Korea, 32 and in Laos7 where WHO has recently assigned an expert to the laboratory currently being organized 25 had shown the usefulness of such a in Vientiane) and experience in Taiwan laboratory • International standard reference preparations, both for c~olipin and , lecithin for cardiolipin syphilitic antigens and also freeze-dried reactive sera, were now available as a result of the work of WHO during recent years.
~.Jii-'i:I4J
palO 18
'lhese preparations could be obtained by national laboratories and serological reference oentres in different cow tries for the checking of their own results by comparison with the international standards. The serum tests in use for the diagnosis of syphilis in the western Pacific Region varied from a single VDhL test in some areas to a battery of five tests l9 in another. The VIhL slide test with cardiolipin had been sa tis" Japan. 38 Careli 0 1" factorily used on a ,dde basis in Taiwan25 and 111 lop in antigens improved diagnosis and had been shown in Taiwan to be more sensitive than preparations previously used. The use of a large quantity of tests was fals€-po.1t~~e ~sult8. • I
!J ,
sometimes confusing as it increased the possibility of
Some participants preferred two tests ( a complement-fix.ation and a fiocculation test) but if only one test was practicable tbe tests of choice were those using cardiolipin antigens. The need of quantitative techniques to appraise the results of penicillin therapy and to enable the evaluation of positive findings in infants was stressed. The problem of false-posi tive findings in diseases such as leprosy38 was l'aJ.se-positive reactions were reported as being frequent in the 2l PhilipPines but not to exceed 1.1% in the 20 age-group of the male population in Taiwan. 25 New techniques using treponema! antigens had been devised which Of these newer tests, the also the treponemal agglutination endeavoured to determine false positive results. treponemal inmobilization test and perhaps best for the purpose. ~e
considered.
.
test and the treponema! complement fixation test were considered to be the such tests with treponema! antigens were agreed to be most valuable tools in syphilis serology, it was agreed that laboratories should not press for their adoption until the national serolOgical service involving convention tests had been firmly established. training should be provided for such personnel. The need existed for an international centre within the western Pacific Region to act as a reference laboratory which could be at the disposal of National laboratories in the Region. The establishment of such a regional It was proposed and unanimously reference laboratory had already been recolllllended by the WHO Expert Committee on Venereal Infections and Treponematoses. agreed that the need for such a laboratory in the western Pacific Region was In some areas of the Adey,uate Region, laboratory procedures were being undertaken by technicians.
•
vlPR/VDT/48 page 19
still present and that the possibilities of its establishment in Japan should be explored. FIG. 6
3.3
Treatment of syphilis
3.3.1 Early syphilis In order to evaluate the results of therapy of any disease, information
..
was required on the natural history of the untreated disease so as to provide a baseline for comparison of therapeutic effectiveness. receive treatment and In the well-known
Oslo study~ where a large number of persons infected with syphilis did not 900-1100 of ,whom were followed for 30-50 years afterwards, the frequency of secondary relapses, benign late syphiliS, cardiovascular and neurological syphilis was 23.6%, 15.8%, 10.4% and 6.5%, respectively. ~hilis
was the primary cause of death in 10.8%. It was agamst this backAs indicated in Figure 6 it
ground that the actual effectiveness of therapy must be appraised and not in relation to the healthy uninfected individual. ,. most important of the levels of prevention. Penicillin was the most effective treponemicidal drug known. 'The times of disappearnce of tre~onemes
has been shown that in early syphilis early diagnosis and treatment were the
from early clinical lesions as well as from the
lesions themselves was shorter with penicillin treatment than with metal
"
chemotherapy.
Seroreversal in secondary syphilis occurred at a 3intila r rate
with both types of therapy (Table VI) and the cure rates obtained with peni-
cillin alone were no better 'When the antibiotic was combined with metal chemotherapy. From a public health viapoint, it was :in the proper management of primary,
•
secondary and early latent cases of syphilis that the control of the disease depended. The treatment schedules used in the \vestern Pacific Region were To cure
many and varied and there was a need for more uniform practices.
syphilis, a continued uninter"lpted peni c1JJi naemia was required. secondary syphilis.
To allow for
a margin of safety this should be continued for a minimum of 10 days in As the treponemes required 25-30 hours to multiply there must be no fall during this period below the minimum therapeutic serum level of penicillin which (also with a safety margin) has been defined as 0.03 units per
ml.
liP R/VDT/48
page 20 SUch serum levels could be otained by repeated high doses of quick-acting preparations but more conveniently with few injections of repository penicillins such as procaine penicillin G with aluminum monostearate (P,ru·i) or with benzathine penicillin. The WHO Expert Comrni.ttee on Venereal Infections and Treponematoses had suggested minimal dosage schedules of repository penicillins in early syphilis and examples of such acceptable schedules ware .9irculated to-the partiCipants (Annex II). These minimal recol1lllendations stressed the need for the use of an initial large dose of penicillin which was considered important from an epidemiological and public health point of view. By so doing a rapid control of infectiousSuperior amounts
•
ness in all cases was ensured and cure in a high proportion of them, even should the patient fail to return for further treatment. being given in many clinics of the world. Retreatment was necessary for clinical relapse, serological relapse, seroresistance and reinfection. Quantitative serum tests were desirable so that Retreatof repository penicillin as compared to the minimum treatment schedules were
..
serological improvement (or relapse) could be accurately assessed.
ment should not be given for sero-resistance unless the serum titre had remained fast for 6-12 months follOwing therapy; if the titre was already declining at six months no action was necessary. Defaulters were indeed frequent in some clinics in the Western Pacific Region. Simplified treatment schedules were considered a great advantage in In an area of Taiwan,25 for exanple, only 44% completed a such a situation.
course of eight injections of PAd on alternate days but the full course was given to 97% when a two-injection schedule was introduced. Some of the PAH preparations previously in use in other regions had given sub-standard levels and durations of penicillinaemia. meet. WHO had therefore fOI~U
•
lated definite minimum requirements which manufacturers I products of PAM should It was unanimously agreed that PAM preparations in the Western Pacific Region should also meet these requirements so that divergent relapse rates should not occur in different clinics as the result of the use of what might appear to be identical dosages of peniCillin.
WPR/VDT/48 page 21 3.3.2 Late §yphilis
The treaUnent of cardiovascular syphilis, the indications for lumbar puncture and the value of information so obtained, were also discussed. It was agreed that an examination of the cerebrospinal flUid was necessary to exclude involvement of the central nervous system in all cases of late syphilis, or of syphilis of uncertain duration. It was also a necessary procedure to be It was frequently done MinUnal. schedules for
repeated as required in known cases of neurosyphilis.
.. •
as a test of cure 1-2 years after treaUnent of early syphilis but not all participants considered such a procedure obligatory. circula ted (Almex II). 3.4 Other aspects One of the difficulties of assessing the relative prevalence of syphilis and the results of its treaUnent with penicillin was the lack of uniformity in the classification of the different stages of the disease, of ]a te
the penicillin treaUnent of late and other fonna of syphilis were also
pa.rt1cular~
syphilis.
It was agreed that the findings of the next meeting of the WHO Expert
...
Collll1littee on VenerEoal Infections and Treponematoses should be awaited since the need for a revision of the differing classifications now in use was present :in all regions of WHO. 4. GONORRlK>EA
.. •
4.1
Extent of the problem While the general picture as regards early syphilis indicated a continued
and satisfactory decline, the situation as regards gonorrhoea was far less encouraging. Although it was true that in many countries both within and outside ~-5O%
the Region the clinic prevalence of gonorrhoea was but
of the
i.mmediate~
post-war peaks of incidence, the fall has now ceased in many areas, although not in all, e.g. Japan,5 where the case-rate per 100 000 population was 272.4 :in 1947, 214.3 in 1950 and only 129.5 in 1956.
In many areas there had been
a definite increase in recent years. In the western Pacific Region there had been an overall increase for 2-3
years in the Australian states of New South Wales, Queensland and Victoria.
'tlPn./VDT/48 page 22 In New South Wales, there had been a 13.3% increase in 1956 and case-rates there had risen from 30.43 per 100 000 population in 1954 to 40.05 per 100 000 in 1955 and 45.39 per 100 000 in 1956.
3
In Hong Kong, 6903 cases in 1951
contrasted with 10 609 cases in 1956,4 a clinic incidence of 435 per 100 000. 8 In the Philippines the increase had been noted since. 1953-1954. (See Fig.7) In a clinic in Taiwan2 there had been 2796 cases reported in 1956 and 3560 in
1957.
Hospital figures in Viet Nam had shewn 3163 cases in 1951 and 4440 in $1
1956.10 In a group of 25 000 soldiers in Laos7 no less than 1000 contracted gonorrhoea during 1955. The situation was more static, however, in parts of JapanD and in Singapore (2690 cases in 1952 and 2584 in 1956).
.
,
FIG. 7 As many cases were concealed, the relatively simple treatment often being given by general practitioners, and antibiotics in many countri61'1 being available over the counter for self-medication, it was evident that gonorrhoea was very far from being controlled in the region and represented a considerable and increasing problem.
4.2 Diagnosis of gonorrhoea Methods and standards of diagnosis of gonorrhoea varied considerably throughout the Region. Gram-staining was not universal and methylene blue was still being employed in some areas (e.g. in Korea ). Cultures were by no means so far widely used 2 ,3 and there was a need for staddardization of methods. The difficulties in the diagnosis of gonorrhoea in females were stressed. It was essen tial to obtain specimens from the urethra and cervix and vaginal smears were not adequate. The use of cultures in addition to smears would •
32
increase markedly the yield of positive results, especially in the female. In a series of 319 female cases reported from Japan19 for example, no less than 89.0% had a negative smear and a positive culture, although these were extreme figures. The importance of accurate diagnosis in the male was stressed so that the disease could be distinguished from non-gonococcal urethritis. 7 In Laos, for example, it had been estimated that approximately one-half of the 'gonorrhoea I cases were cases of non-gonococcal urethritis. Here, no attempt was made to differentiate the two disorders, there being 5ODO cases
.-
WPR/VDT/48 page 23 of both diseases in 11 of 14 provinces (population 1 200 000) in 1959. gonococcal urethritis was relatively insensitive to penicillin. looked because of inadequate diagnostic procedures. Non-
Sometimes,
however, the "condition" might be of gonococcic origin, -this fact being overOn the other hand, a diagnosis of gonorrhoea was sometimes erroneously made and the failure of a discharge to clear up following penicillin treatment might result in an unfair appraisal of the value of the penicillin treatment of gonorrhoea.
•
4.3 4.3.1
Treatment of gonorrhoea General The substances, preparations and dosages used for the treatment of gonorr-
.. ~
poea differed widely throUbhout the Region.
Until now, in most parts of the
1l/estern Pacific Region, P,&-j had been the penicillin preparation of choice for the treatment of gonorrhoea although mixed types of penicillin preparations had been used in some areas particularly in Laos and Australia, as had streptomycin in French Polynesia. pond to penicillin. Penicillin had been the antibiotic most used, but it was disturbing that gonorrhoea was apparently no longer responding as well to repOSitory penicillins, and today it was necessary to use larger doses of penicillin than formerly.ld,43 Cure rates which at one time had been in excess of 95% had been reduced to approximately 70% in some areas. 39 ,40 Particularly did this apply to benzathine penicillin and to PAl1. In a clinic in London in 1957 the failure rates were With 1.2 mega
In many areas the tetracycline antibiotics, chloramphenicol res-
and other systemic and local measures were given to patients who failed to
•
.
nearly four times what they were with a lesser dosage in 1954. of benzathine penicillin the failure was
units of PilH a failure rate of 17.2% had been obtained, and with 1.2 mega units
~.4::.39 'Ibis was supported by ex-
perience from a New South Wales Government clinic, Australia (where 12% of failures were occurring with 300 000 uni td l'JU-i in 195r), from China, Cambodia 18 and Hong Kong (where approximately 3.0% of resistant cases were being noted 18 in males and 11.7% in female prostitutes), and Japan, Korea, Laos, the lO 8 Philippines and Viet Nam but not from Singapore where doses of 0.6 mega uni ts of PAH in males and 1.2 mega units in females had proved satisfactory for some years.
WPR/VDT/48 page 24 In a WHO survey undertaken in 1955 it was shown that 84.4% of clinics in major ports of the wOlld used doses of penicillin of 0.6 mega units or more tor the treatment of gonorrhoea. 47 In the WHO Weatem Pacific Region, the doses stated to be in current use were varied but ranged from a minimum of 0.4 mega units to 2.7 mega units of PAH given over three days. It was significant that
here too the apparentlJr higher failure rates currentlJr being obtained were observed in spite of the use of a considerably higher dosage of penicillin than formerlJr. 'fhere was thus a need to obtain more accurate information regarding the present status of the "ffectiveness of penicillin in gonorrhoea in the western Pacific Region. The suggestion that the WHO Regional Office should circulate to participants a simple questionnaire concerning the doses and preparations of penicillin used in the treatment of gonorrhoea, and t he results obtained throughout the years, was approved. control, the From the point of view of venereal disease situation 111 many areas 111 which the numbers of cases were in-
•
•
..
creasing parallel with the proportion of failures with higher doses of penicillin than formerlJr used was very disturbing. 4.3.2 Failures to penicillin (a) Clinical aspects
Possible reasons for repository penicillins becoming less effective in the treatment of gonorrhoea might exist in the host, the environment of the 40 patient or in the organism. It had been stated that gonorrhoea may have become a milder disease than formerlJr. It had certainlJr fewer complications • even in those cases which failed to treatment. The rarity of complications 1 10 was noted in Australia,3 Singapare and Viet Nam. In Singapore there had onlJr been 11 complicated cases out of 2835 pati~nts
with gonorrhoea treated Reports had suggested
in 1956 compared with 55 out of 2965 treated in 1952.
that a "narrier staten might sometimes exist in both sexes and the possibility that such might be produced by the widespread u::;age of Jenicillin was considered. One possibility WlaS
thnt penicillin failures resulted from the paniIt was reported from Japan,
cillin given not reaching the focus of infection.
for example, that 111 penicillin-treated women gonococci might apparentlJr oometimes be recovered from the vulval orifice when it was no longer to be
WPR/VDT/48 page 25 to be fQund in the urethra or cervix, although such cases might be found in women reinfected whlle carrying penicillin in the blood. In one series of patients prosented, the failure rates with penic:iJ.lin
were appreciably higher in an ethnic minority 4J and i t was
~.elieved that a too
early return to the same sexual environment in these cases might have been • partJ.y responsible, not only by providing more reinfections but by encouraging a lessened sensitivity of the gonococcus to the antibiotic by repeated passages in patients with declining and orten low penicillin blood-levels.
•
(b)
Laboratory aspects
That the gonococcus had become less sensitive to penicillin was suggested 8 by data from Hong Koni and London. 39 ,4O,41 Gonococci might have a fairly wide range of ~nicillin
sensitivity and clinical failures had been shown to It had been noted that the vast majority of failures
be related to the peniCillin sensitivity of the gonococcus as determined by cul ture before treatment. occurred in the patients whose gonococci were initially less sensitive before 4O treatment than in those carrying the more sensitive strains. Owing to lack of standardization of method, however, laboratories in the same town might show variations in the results of sensitivity tests of the gonococcus to peni18 cillin and there was a need for such standardization so that results in different centres and in different countries could be compared. As no single-cell culture work was known to have been undertaken to date, there was no firm evidence to show whether the gonococcus had become less sensitive to penicillin by developing new metabolic processes, i. e., had "acquired" some degree of resistance, or whether - as seemed more likely - the lessenod sensitivity had arisen from selective breeding of the relatively insensitive strains. There was an urgent need for more research on this subject and the suggestion was put forward that an International Gonococcus Centre, anaJ.agous to the WHO Intemational Treponematoses Laboratory at Baltimore, USii., might be established to consider these and similar problems on an intemational scale. (c) Future considerations
'!
In view of the increasing failures with repository penicillins in the
dosages reported, the possibilities of action to meet the situation were:
WPR/VDT/48 page 26 (a) to change to another antibiotic or (b) to continue with penicillin but
to vary the dose l preparation or method of administration. Of other antibiotics used for the treatment of gonorrhoea, generally successful experiences had pertained with tetracylines, chloramphenicol, spiramycin, erythrontYcin, and triple-sulfonam:ide and tetracycline combinations. These had the considerable disadvantage of being more costly than
penicillin and had the disadvantages, as well as the advantages, of being given by mouth. 4l Failures also occurred wi. th these antibiotics and it is probable I if they too ,.ere widely used, that the gonococcus might in time become less sensitive to them also. The general use of erythrontYcin was to
.. •
be discouraged as it was a widely held view that the more potent anti-staphylococcal antibiotics should be kept in reserve for fulminating cases of staphylococcal septicaemia. Even if penicillin was successful in only 70% of the cases of gonorrhoea, it was still a very useful drug, and i t was the general view that i t should still be retained for routine use in preference to a change to t'ther antibiotics. But, in order not to present the gonococcus with easy steps whereby
a further lessened sensitivit,y to penicillin might result, a considerably higher peak of penicillinaemia was necessary than was cb'.r,ined wi. th the individual doses of up to 1.2 mega units of Pal'! stated as being used in the Region. If relatively small doses continued to be used "resistance" was likely to , 43 mcrease. Appreciably better results had been reported from two areas in which
1.2 mega units of an "All Purpose" penicillin (300 000 units of potassium cry;:;talline penicillin, plus 300 000 units of procaine penicillin and f:IJO 000 ' t s 0 f b enza th' , '11' , one series only 7.9% failures Ul'U me PeIU.Cl. m )41 was used, m 41 being noted in 95 persons treated. It was recognized that such a prepara41 tion provided a higher initial peak of penicillinaemia than that obtained with a similar dose of PAN (and this, if sufficiently prolonged, would discourage the further development of lessened sensitivity) but at the same time would still provide the more prolonged penicillinaemia - the sO-Called "penicillin tail" - which had been obtained with PAN and which was considered to have been epidemiologically important in so far as time was provided during which contacts could be secured and the person therefore was unlikely to
•
'lJPR/VDT/48 page 27 become reinfected. 43 Moreover the penicillin "tail" in the treatment of gonorrhoea may ha..,e also tended to reduce the reservoir of syphilis. 43 On the other
hand, such combined preparations were substantially more expensive than PAM and the possibility that the penicillin "tail"might itself in time foster further lessened sensitivity to the gonococcus could not be overlooked. Orally administered penicillin preparations, including phenoxymethyl penicillin (Penicillin V) had given inconstant results, and no antibiotic preparation had so far been developed whereby gonorrhoea could satisfactorily be cured with a single tablet or capsule. It was obvious that the control of gonorrhoea, by reason of theincreasing numbers of cases, the increasing numbers of failures to increal:ling dosage of pEilicillln, the probability of a lessened sensitivity of the gonococcus to penicillin, and the considerable problems posed in deciding how it should be treated in the future, had suffered a considerable reverse. It was considered that the penicillin should continue to be used by injection for the routine treatment of gonorrhoea,· t.\:t the glooll\Y conclusion could not be escaped that the overall situation was likely turthcr to worsan in the future. The decision was taken that the question of the dosage and preparation of penicillin to be recolllllended in the treatment of gonorrhoea, in view of the various considerable problems related thereto, should be referred to the next meeting of the WHO Expert Colllllittee on Venereal Infections and Treponematoses. Such reconunendations were urgently required and in tile meantime it was gener-
•
ally agreed that in most areas, to prevent the development of a further lessu:ed. sensitivity, the dose of penicillin - whatever the preparation in current use might with advantage be substantially increased. 4.4 Other items Other items considered included venereal disease expenditure, defaulter rates, ophthalmia neonatorum and vulvovaginitis. The apparent lessened importance of venereal diseases in recent years had resulted in some areas in reduced budgets, with the consequently less efficient contact tracing and case-holding machinery, and higher defaulter rates. Indeed, it was suggested The same increased that reduced expenditure on venereal diseases might in some cOWltries be partly responsible for the increased prevalence of gonorrhoea.
WPR/VDT/48 page 28
preyalence, however, had also been noted in areas where budgetary allocations had been maintained and, in one area at least (tSingapore), actually increased. 'Ine preventable condition of opthalmia neonatorum was still being enl countered in many countries of the western Pacific Region. In Singapore in the five-year period 1952-56 some 248 cases had been reported (Fig.8). In
some hospitals the use of prophylactic drops was being discoDtinued because the condition was now easy to treat when it occurred with local and systemic penicillin and any risk of chemical conjunctivitis arising from the use of prophylactic drops themselves was thus avoided. Although discontinuation
.,
ot
routine prophylaxis might be justified in countries where maternity patients and their offspring were kept under strict medical observation tor 10-14 days as a routine, such a practice was dangerous in areas in which, to obtain the
FIG. 8 greatest maternity benefit for the greatest number, obstetric patients were being discharged from hospital within a few days of confinement before gonococcal ophthalmia might be expected to become evident. The recent recommendation of the American SoCiety for the Prevention of Blindness that prophylaxis be continued, and the reaffirmation of faith in silver nitrate (although not necessarily the best preparation in tropical areas) by many writers 48,49,50 was noted.
An interesting outbreak of gonococcal vulvovaginitis in Japan which occured in young children in a time of water shortage when the public baths were not properly cleansed was reported. 5. NQI...QCI{OCOCCAL URETllliITIS
5.1 Extent of the problem In a number of countries of the western Pacific Region non-gonococcal
urethritis was assuming greater importance than gonorrhoea in the male.
In
the Government clinics in 8,ydne;: New South Wales, for example, there have been 1185 cases of non-gonococaal urethritis in 1956/57 as compared with 1125 cases of gonorrhoea. In the previous year there had been 1182 cases of non-
gonococcal urethritis as compared with only 905 cases of gonorrhoea. It was 32 increasing in prevalence in Korea where it was four times more impOrtant than 8 gonorrhoea, as well as in the Philippines and was also IIlOre imporUnt than lO gonorrhoea in Viet Nam and parts ot Japan.
WPR/VDT/48 page 29
In other areas it was less important than gonorrhoea ar.d was not markecLq increasing. In Hong Kong 4 there had been rna cases in 1953 and 776 in 1956 when the clinic case rate had been calculated at 31.8 per 100 000. In S1llgaporel there had been 529 uncomlJlicated cases in 1956 (2584 of uncomplicated gonorrhoea) as compared with 696 cases in 1956 and 217 cases in 1952. A number of the ,~gures presented under-emphasized the condition by comparing non-gonococcal urethritis - a disease of males - with the total numbers
..
of gonorrhoea cases in both sexes.
In some areas no attempt was made to differIn Laos,? for example, it
entiate non-gonococcal urethritis from gonorrhoea. non-gonococcal. urethritis.
was suggested that at least one half of the gonorrohoea cases m1.ght be c aS8S d It was probable that cases of non-gonococcal urepenicillin~esistant
thritis were mistaken for cases of areas. 5.2 Etiology
gonorrhoea in some
No conclusive proG.f could be established that simple bacteria, ~
spi~
chaetes or pleuro-pneumonia-like organisims (which were denxmstrated during 35 one field visit) were responsible for the bulk of cases. Although antibioticresistant staphylococci might be found in the urethral culture of some clinically resistant cases follOwing treatment,18 the majority of cases were 27 "abacterial" in nature. Trichomonads could be recovered in some instances but the percentage of cases in which they were found differed widely throughout the world. 35 In the western Pacific Region trichomonads had so far been found in only relatively few cases. The possibility of a virus cause had been considered by many workers and on the occasion of another of the four field visits the so-called bodies' found in:urethrll scrapings were demonstrated. I
..
inclusion
Although some workers 25 considered these inclusions to be significant,2', others did not. Fundamental knowledge is lacldn~.
Research in this field seems to
have become static.
Renewed efforts involving the vixologist, bacteriolo-
gist and protozoologist, which is greater in scope than that which could normally be undertaken in the venereal disease clinic by the venereolOgist, should be encouraged.
,JPR/VDT/48 page .3)
5.3
Treatment
The tetracycline antibiotics (with and without oleandomycin) had given 3? the best results but these e.. IgS were relatively expensive. Untreated l the di"ease would cure in about .3)%
of cases.
Using sulfonamides or streptomycin l
approximately f:IJ% could be cured relatively cheaply.
To increase the cure rate to or above 00% the cost had to be increased six or more times 3? and for
reasons of economy it was sometimes necessary to use the cheaper methods including urethral irrigations which had proved satisfactory in patients who attended l regularly.
A combination of streptomycin and sulfonamides has been
reported to be successruJ. in some areas. In cases in which trichomonads were found no really satisfactory treat-
ment was available 1 although Japanese workers claimed good results wi th trichontV01n l o a n antibiotic developed in Jflp..31ll.
Reports indica ted that amini trozole
given by mouth had not proved effective. 3 ?
6. 6.1
OThER VENEREAL DISEASES
Chancroid
6.1.1 Extent of the problem Chancroid was the most important of the "other venereal disease" in the western Pacific Region. 1956. In Cambodia" 11
no less than 3155 cases were seen in In Hong Kong 4
II
In a clinic in Viet Nam"lO chancroid was responsible for 8 out of 35 of
all venereal disease cases seen in 195?
the case rate in 1956 '0
was calculated at 66.2 per 100 000 population. Amongst 25 000 soldiers in Laos7 in 1955 1 no less than 350 cases (14 per 1000) had been encountered and it was more than four times more connnon than primary syphilis. It was also l (where the' () had more than primary SYPhilis in China (Taiwan), in Singapore l been 64? cases of chancroid in 1956 compared with 351 cases of early "yphilis) 4 and in Hong Kong where in the first eleven months of 195? there had been 626 cases of chancroid and only 16 cases of primary syphilis. The relative imporlance of chancroid in these areas in the diagnosis of genital sore was obvious. Chancroid was stated to be r are :in Australia, 3 French PoJ..;ynesia and :in the 8 PhiliPPines where exc1ud:ing Manila, in 1956 there had been only ? cases of Declining prevalence rates were generally reported (e.g. in Ch:ina (Taiwan)" Japan l S ,24 Hong KOng,4 Korea, the chancroid compared with
•
96
of syphilis.
.J"PR/'VDT/48 page 31 Philippines,
B Sjngapore1 and Viet Nam. 10 In Japan, 5
the case rates per
100 000 were 52.3 in 1947, 19.0 in 1950, 14 .. 4 in 1953 and only J.4 in 1956. 4 In the Japanese Self-Defence Forcel the incidence of chancroid had declined from 4.8 per 1000 in 1952 to 0.8 per 1000 in 1956. cases seen in 1956 compared with 2347 in 1951. In Hong Kong,
4
the 1614
In Singapore,
l
there had been 647
cases (excluding mixed infections) in 1956 compared with 1494 in 1950.
6.1.2 Diagnosis • The essence of the management of chancroid was if possible to exclude syphilis by repeated darkfield and seI'Ulll examinations. Such was not attemplO ted in a number of areas. In Viet Nam approximately 50% of patients with ;
chancroid had, on further investigation, been shown also to have syphilis. Syphilis, from the public health point of view, was by far the more important disease and as its prevalence declined its distinction from chancroid became even more important. Horeover, if darkfiSld examinations were not made patientt.s with chancroid who also had a positive serology due to late latent syphilis or :to yaws or other endemic treponematosis would tend to be diagnosed as cases of sero-positive primary syphilis and treated with peniCillin. If, as was
likeq, the serology in such cases did not reverse these patients would unfairly be classified as cases of early syphilis falling to penicillin and the true appreciation of the value of penicillin in the treatment of sl'PhiJ,is would thus be unnecessariq prejudiced. Smear and culture methods for the detection of H.ducreyi were often unsatisfactory in practice. Culture methods for the diagnosis of chancroid particularly offered considerable technical and administrative difficulties. Moreover, the finding of H. ducreyi by smear or culture did not exclude the possibility that T. pallidum might also be present in any particular case.
" •
The use of Dmelcos for skin testing for the Ito-Rienstierna reacti on might be of value in individual cUies 11'1 areas in which chancroid was uncommon. In areas where it was prevalent, however, skin tests had a much
more limited value.
A positive skin reaction took some time to develop and A positive reaction therefore Skin
once positive it might persist indefinitely.
might only be related to a previous rather than to the present sore. prevalence of chancroid in a colllJllUlli ty.
tests were useful, hClifOVer" on a mass basis in the determination of t he general For exaJlple" in a survey of pros-
IIIPR/VDT/48 page 32
titutes undertaken in Taipeh City, Taiwan, in 1954, positive skin tests for chancroid were noted in 48%.34 6.1.3 Treatment Sulfonamides, streptomycin, the tetracycline antibiotics and chloramphenicol in sufficient dosages had all been shown to be effective in chancroid as had penicillin. In areas in which proper diagnostic procedures could be used to exclude syphiliS, sulfonamides were agreed to be the drugs of choice, as they would not mask syphilis if pres en t and interfere with the results of the diagnostic tests for this didease. In some cases, the course of sulfonamides
might have to be prolonged for ten days,
In areas where diagnostic tests or
-
follow-up was possible for cases of genital sore it seemed logical to use penicillin in full doses as for syphilis with sulfonamides in addition if necessary. 6.2 Lymphogranuloma venereum Lym~hogranuloma
venereum was present in most parts of the region but, in
contrast to other venereal diseases, did not represent a significant public health problem. In the Philippines (excluding Hanila) there had only been 5 cases in l 8 1956 and there had been only 40 cases in Singapore whereas there had been 143 cases in 1950. In Hong Kong,4 there had been 166 cases in the first 11 The months of 1957, 140 in 1956, 286 cases in 1954 and 197 cases in 1951. clinic case rate in 1956 was calculated at 5.7 per 100 000.
In Cambodia,ll 10 507 cases were reported in 1956 and in a clinic in Viet Nam in 1957 three
cases of lymphogranumloma venereum were encountered in every 35 venereal diseases patients trG6te4. Frei tests in prostitute in Taiwan had shown positive skin reactions, 18.8% of positive reactions being noted in a survey of prostitutes in Taipeh City (Taiwan) in 1954. 34 6.3 Granuloma inguinale Granuloma inguinale was generally a rare disease throughout the Region. l No cases were seen in Singapore between 1950 and 1956, and only three cases ( in aborigines ,from the Northern Territory) were encoUlltered in Australia in
iPli/VDT/48 page .3.3 1956• .3 The clinic case rate per 100 000 population in Japan 5 which was 1.2 It
in 1947 had declined to 0.6 in 1950, 0.2 in 195.3 and to zero in 1956. had also declined in the Japanese Self-Defence Forces. 6.4 Other conditions
A high incidence of condylomata acuminata had been noted in prostitutes in Taiwan, being found in 8.8% of a series of 944 promiscuous women. j4
The
.. •
disease contracted in Asia had been transferred to other parts of the world. 29 29 The lesions of molluscum contagiosum had also been noted. It was well lmown that many persons attending venereal disease clinics on suspicion of venereal disease were found after investigation to have no such disease.. In Singapori in 1956, for example, of 24 551 new patients attending the venereal disease clinic 4805 suffered from venereal disease and apprOximately 80% from non-venereal conditions, including anxiety.
7.
REACTIONS TO
PE~ICILLIN
7.1 Nature and extent In view of severe anaphylactic reactions following the use of penicillin
which had occurred in recent years in many countries including those of the Western Pacific Region, a special session was reserved for a discussion on penicillin sensitivity reactions. Reactions to penicillin included tazic reactions (which today were extremely rare); microbiogenic sequelae (bacterial resistance, bacterial overgrowth, bacterial lysis, i.e. Herxheimer reaction (therapeutic shock) and therapeutic paradox), and allergic or sensitivity reactions of which anaphylaxis was the most important as it was sometimes fatal.
•
Penicillin sensitivity reactions were often apparently related to previous allergy in the patient - particularly to previous sensitivity to penicillin, to the number of injections of penicillin previously given, the interval between them, to the type of preparation used (more common with quickly-absorbed preparations than with repository ones) and to the type of penicillin given (more common with certain special selective types of penicillin) and to the period any particular preparation had been in use (more cOllllllDn with any penicillin preparation which had been in use for some time). They were
WPR/VDT/48 page 34
also more common following intravenous rather than in tramuscular injection and following intramuscular rather than oral administration. occasion. Some deaths from penicillin had been reported from most countries of the Region but fatalities had been rare in venereal disease clinics in comparison with private practice and general hospitals. disease clinics and less commonly outside. Actual figures of incidence of penicillin reactions were difficult to obtain but in a WHO survey involving 626 551 patients treated with (usually repository) penicillin preparations in 18 countries over a five-year period 52 there had been only nine deaths - or 1 in 70 000 cases treated. Most deaths17 in all - were reported at the seminar from China (Taiwan); ~/UNICEF
They were less
common in children who were likely to be receiving penicillin for the first
This might have been the case
because repository penicillins had been those most usually used in venereal
but in the
- Assisted VD control project the incidence of deaths was only 1 It is probable that a number of fatalities which
in 44 000 persons treated. allergy had been elicited.
•
did occur could have been prevented if available histories or penicillin
The occurrence of serious reactions from penicillin which were apt to occur in a doctor I s consul ting room rather than in hospi tal could, when in persons well-known in a community or in a village in a rural area where a treponematosis-control was being initiated, be extremely harmful to the success of the programme by the publicity engendered and the alarm created. Allergic reactions to penicillin had hampered the tJHO-as3isted venereal disease control programme in Taiwan. 25 It was agreed, without minimizing the seriousness of allergic reactions 'to penicillin that their importance to the public health programme should not be over-emphaJized. The frequency of fatal reactions to penicillin therapy in the treatment of syphilis vms certainly less than that encountered in the days of metal-chemotherapy (0.033%)53 and this point should be repeatedly stressed. P~b:p.q
relations departments could play an important role in this respect.
A
number of participants stated that, in spite of the many thousands of injections of penicillin for which they had personally been responsible over periods of
·~Fi./VDT/48 page 35
up to 15 years, they had not themselves so far encountered a death from anaphylaxis. 7.2 Prevention of penicillin reactions It was essenticl. that the indiscriminate use of antibiotics should be
discouraged not only to prevent the induction of penicillin allergy but also
•
to minimize the fostering of bacterial resistance (e.g. the gonococcus to pEilicillin). This implied the restriction of the sale of antibiotics for systemic or topical application over the counter except on a doctor's presCription, restriction of the use of topical methods generally, and the discouragement of the use of antibiotics in trivial conditions. Jl.ntibiotics should be given only in those cases in which a worth while therapeutic response might reasonably be expected, or on well-Tecognized prophylactic indications. Hethods of detecting penicillin sensitivity such as skin tests (patch, scratch and intradermal), conjunctival tests and the oral use of penici.ll:ln troches had not proved entirely satisfactory as both false-negative and falsepositive results might be obtained. Skin tests (1000-2500 mits of cry.;;talline
.
..
penicillin given intradermally, the result being read in half an hour) have been used in Korea32 and scr~tch tests have been used in China {Taiwan).25 Scratch tests in Taiwan gave 0.5-2.0% positive reactions and posed a problem as to what should be done in these cases. It was felt that an adequate history and the withholding of penicillir. from patients Imown to be sensitive to penicillin, and from patients with a history of asthma, angio-oedema, urticaria and other allergy, was a more practicable approach than the use of skin and conjunctival tests or the use of penicillin troches. Apart from having had previous penicillin therapy there were other ways in which patients might have become sensitized to the antibiotic.
It was indica-
ted that minute traces of penicillin sufficient to induce cillin even after as much as 24 hours of boiling.
~
allergic response
might persist in syringes which had been used for the administration of peniSuch traces might accumul~te in sterilized water used for the sterilization of syringes. 5l ,54 Although,
in venereal disease clinics, the injections given were usually of penicill:ln this did not apply in private practice, where one syringe was often used for the injection of many substances. The possibility that some patients
page
WPR/VDT/48 36 were being sensitized in this way deserved consideration. an epidemiological factor in its spread. Uncleanliness of
syringes might be one of the "hidden sources" of penicillin sensitization and The use of separate syringes and
dry sterilization might be considered in polyvalent practice. Important in the prevention of fatalities was the ready availability of resuscitative measures. That a special anti-anaphylactic kit should be availp~ong
able in private and public clinics, hospitals and surgeries where penicillin was being given, was unanimously agreed. the substances suggested for inclusion in such kits were adrenaline, coramine, antihistamines,aminophillin, cortisone and possibly penicillinase (when available). The Seminar appointed a Horking Party~ to consider this matter in further detail and its detailed findings are presented in Annex III. It was agreed that, providing physicians took the necessary steps before administering or ordering the administration of penicillin to determine whether their patients had a previous history of allergy or of penicillin sensitivity, and had arranged for an emergency kit to be readily available for use if and when reactions occurred, that all reasonable steps had been taken to prevent the occurrence of such reaction3. It was also felt that phYSicians, medical students and nurses should be instructed concerning reactions to penicillin and the means by which their frequency and seriousness could be minimized. 8. VENEll.EAL DI3&i.:iE PrlEVENTION AND OON'llWL
.
I I '
8.1
Introduction There was a need for a wider outlook on venereal disease control. 42
In some countries the control of venereal disease was limited to the periodical examination and treatment of prostitutes and similar groups which, however, Venereal diseases were often those of the static female and the itinerant male. 3O '!he a Dr. Dr. Dr. Dr. Dr. Dr. 'ii. Frtihlich (~O Taiwan) Chairman G• i·l. Thomson (Hong Kong) L. r1. Ibarra (Philippines) Nguyen Van ut (Viet Nam) T. Guthe (JHO Geneva) Y. Onoda (Japan) Dr. R. Pierron (observer)
represented but a small part of the female population in a country.
WlR/VDT/48 page Yl
prostitute protect.
was but one facet of the problem for the prostitute was a member The venereal disease control progralllIne had broader functions and administra~
of the general cOlllInuni ty which it was the duty of the medical profession to included further activities in the overall progralllIne of the health
tions on the basis of an epidemiological rather than a clinical approach.
A
wide outlook by health administrations was necessary at all levels of prevention and efforts should be directed towards (a) health promotion, (b) specific
..
protection, (c) early recognition and prompt treatment, (d) disability limita42 These preventive methods have been applied to tion and (e) rehabilitation. syphilis in Table VII and were illustrated in Fig. 6. TABIE VII
Epidemiological case-finding was an important cOlllInunicab1e disease principle which should be more widely used in venereal disease control on a national 42 and international scale. Case-finding methods included contact tracing, serum testing of expectant IIlOthers and other special population groups. was assisted by health education. 8.2 Notification of venereal diseases Practices regarding the notification of venereal diseases varied throughout the Region. It was the practice to notify cases and contacts by name to the Laws in most Australian states provided Governor of the Prefecture in Japan. The whole
for notification of cases first by number only and later by name and address if the patient defaulted. 3 In the Philippines notification by name was required for cases only but the law was described as doctors could be fined if they failed to report. name did not occur. officially. Venereal disease treatment should be free to all and it should be confidential. Notification by name frequently resulted in persons fearing to disclose their infections and.. 1aws involving compulsion in matters of venereal disease control, the enforcement of which could be regarded as breaches of confidence, tended in time to be ignored. I
dead I .
In French Polynesia
Elsewhere notification by Studies in Tokyo,
Much venereal disease was not notified.
Japan,23 indicated that only one-tenth of venereal diseases were reported
WPn/VDT/48 page 38 8.3 Case-finding 8.3.1 Contact tracing Early case-finding and early ,
tre~tment ~
were the most effective methods
for the control of venereal disease.
The clinic facilities for the tracing
of contacts of patients known to have venereal diseases vffi'ied throughout the Region from no facilities at all to organizations involving up to 12 ancillary ll staff. l ,14 For example, there was no venereal disease service in Cambodia and no contact tracing in Korea32 and only minimal contact tracing in Japan, where it had but recently been introduced. IS It was noticeable that in areas where no contact tracing machinery existed that the proportion of the total venereal disease which was traced by such methods was small, while in areas where efficient contact tracing machinery was established a high proportion of venereal disease cases, especially in females, was uncovered by this measure. In Japan, for example, the contact tracing efficiency index was only 2.S%S and only 0.2% males and 0.8% females with venereal disease attended as a result of contact traCing.
1S Not only was contact tracing machinery necessary vuch an organization, of course, required
in an efficient venereal disease control programme, but persons undertaking this work must be proptrly trained. adequate fund3. That defaulter tracing, in addition to contact tracing machinery, was necessary was indicated by experience in Japan where there were 32.2% de23 In Singapore14 even faulters in 19S1, 87.2% in 19S2 and 51.9~ in 1953. in 19S7 only 29% of female patients continued to attend on their own initiative and 71% had to be contacted to prevent default. It was felt that private physicians themselves were not in a pOSition per30nally to undertake or organize contact tracing as they had no facilities with which to do so. A service for this purpose should be available to them It was in the private physician's own interest through the health department. their patients.
•
to secure contacts for treatment if possible and some already did so through "
8.3.2 Examination of special groups Apart from contact tracing, oth~r
m£thods, of case-finding included serum
and other examinations of certain popule tion groups (i.e. expectant mothers,
WPrl./VDT/48
page 39 persons about to be married, service inductees, and persons in whom the prevalence of venereal disease might be expected to be high, such as seamen, waitresses, bar and tea-room girls, etc. syphilis.) and these two groups are considered were also found in prisoners. For rates found in such groups see under separately. High sera-positivity rates Soldiers and seamen often had relatively high venereal disease rates JU.l methods of case-finding were complementary,
but the most important group for ante-<latal serum testing was considered to be 42 that of expectant mothers, especially in less developed countries. Those in charge of venereal disease programmes should endeavour to ensure that this valuable case-finding and therefore prGventive measure against syphilis should be integrated into maternal and child heal th pr ogrammeli. ~
J\ t the
same time they should be prepared to advise on what procedures should be adopted in the case of positive reactors. 8.4 Maritime aspects of venereal disease control 8.4.1 Introduction Seamen, as itinerants, were particularly prone to venereal disease and sero-positivity rates were substantially higher in this group than in the
popul~tion at large. In Japan,13 for example, where in 1957 there were 198 927 seamen and the 68 main ports handling 4 821 129 tons of shipping. From data based on random sampling 10.8% of seamen had venereal disease in 1953 and 5.6% in 1956 compared with only 2-3% in the remainder of the Japanese popul&tion. Of the venereal diseases encountered in seamen 49.4% was syphilis, Sero34.7% gonorrhoea, 14.4% chancroid and 1.5% lymphogranuloma venereum.
..
positivity rates in sailors were 7.3% in 1954 and 8.1% in 1955 compared with 3.1% and 2.5% respectively in the general population. In the Japanese Naval Self-Defence Forces 24 the incidence of venereal disease increased in 1956,
..
whereas it had fallen in the land-based forces (Fig.9). 4
In Hong Kong in
1956 on the other hand, whereas 233 378 seamen had entered the part, only two cases of infectious syphilis and 122 cases of gonorrhoea were noted in seamen.
FIG. 9 8.4.2 Brussels Agreement The need for further co-opeEation between health administrations on questions of venereal disease in seamen is illustrated by Fig.10, which is
-.PR/VDT/48 page 40 a contact chart by geographical areas of exposure of infected seafarers in the Uni ted states Herchan t Harine.
FIG. 10 The Brussels hgreement of 1924 (admlnistercd by ,iliO since 1948) had provided for free treatment of seemen of all nationalities in the countries adhering to the ~greement. This mutually protective arrangement was one of the Unfortunately,
earlies t int ern r. tional measures in the field of public heal tho
there \!(;re still :iome se,'~faring countries in the l'lestcrn Pacific Region and elsewhere which either hr.d not ratified or had not adhered to it in spi to of repE,ated recommendations ofdorld Health Assemblies. It was suggested that <" '
the places 2nd times of venereal disease clinics existing in countries which had not so far adhered to the BrusJels Agreement should, with a suitable indicntion thnt the treatment given in them would be upon payment, be included
in the International Directory of Venoreal Disease Treatment Centres, a new revision of which is currently being undertaken by the world Health Organization.
8.4.3
Prevention of
venere~
disease in seamen
The closure of tolerated brothels did much to reduce temptation especially in seamen .:md other travellers with a subsequent resultant fall in incidence at' the venereal diseases in these persons in the are&s concerned. At the same
...
,
time it was necessary to provide alternative and more elevating amenities during the time thr.t seamen spent in port:;;. In some parts of the western Pacific
Region (e.g. Singapore) some excellent work had been done in providing suitable hostels for seamen at an economic charge in whlch recreational and cultural activities were fostered a3 an altern"tive to the bawdy house and bar. all coun tries j hO\oJever j m2.de adequate provision for foreign s(,amen. 13 Not Such
~I
a social moasure was regarded a3 a very uaportant element of venereal disease control. PrevGntive and prophylactic measures were used by some seamen within the Region, but not used by many others. by 30-50% of seamen, washing by ally. Fur example, in Japan
• 13 condoms were used Of 952 seamen
40-50~
and proFhylactic jelly only occasion-
Penicillin 200 000 units) given orally had been tired.
on 17 ships who took the tablets before exposure, there were only seven cases of gonorrhoea in four months, and three oftllese seven proved not to have taken the tablets, whereas there were 27 cases amongst 1380 seamen in the control group.
ilPfi/VDT/4B page 41 8.5 .Military aspects of venereal disease control TIle presence of military forces had presented, and still do in some areas,
considerable problems in venereal disease control in many countries of the T,r 'f' ' 7,10,36 ~ ' ' ues t ern PaC1 1C R eg10n. llle venere al disease problems were related to the size and movement of the armed forces in question. J6 Hilitary personnel, by reason of their age and their being far from home, were prone to contracting • venereal diseases from prostitutes who congregated to supply the demand they created. JO ,36 Venereal diseases were more prevalent in military forces than in civilians. 24 In Japan in 1951 the military venereal. disease case rate Vas 38.9 per,10C)(Y compared .lith 5 • .2 per 1000 in the civilian populatioia. In 1956 the figures were 8.3
...
and 1.6 per 1000 respectively. blIIOllg the military, the venereal disease rates . pr1va . t es than lJl . 0ff' were hi gh er lJl 1cers. 24 I n S' lJlgapore, 12 th e army venere al disease rate was 86 per 1000 men in 1949, 54 in 1951, and only 20 in 1955. A high venereal disease rate (57.2 per 1000) was reported amongst 25 000 7 soldiers in Laos in 1955. !
Methods of prevention included the making of the worst areas into "off limits", the regular medical examination and treatment of prostitutes in military areas, health education of the soldiers themselves, the use of condoms and other prophylactics, and the routine serum testing of inductees 36 into the army which was the practice in one area' at least. Ideally, such serum testing should be repeated upon discharge so as to protect the civil population. The need for co-operation between military and civil authorities
•
in matters of contact tracing and in the approach to venereal disease problems . 6 7 12 14 16 36 in prost1tutes was stressed. " , " If the local prostitutes repre-
sented a venereal disease problem to the military, no less did the presence of the military represent a venereal disease problem to the local community. 8.6 Health education Health education used to foster venereal disease control should include information concerning the venereal diseaSeS and their effects, sex education and preparation for marriage.
Venereal disease education was but one facet
of health education, and health education was par t of a full €It' education. There was an absence of sex education in many parts of the Western Pacific
WPR/VDT/4B page 42 Region, particularly in regard to senior schoolchildren. The subject of vene-
real diseases was still often taboo, e.g. I syphilis! was still regarded as a shameful word in Viet Narn. 10 The health educator should act through existing 5 religious and community leaders, rather than on his own. In Japan, special emphasis was laid on the education of youth leaders. were basic steps. To advance community spirit, the possession of a sense of responsibility and an objective in life h
happy marri~ge waS one such goal and that in many areas Social In some '"
of the world economic factors were such as to prevent its fulfilment. medicine should assist in trying gradually to right this situation. marriage.
areas, married persons expose themselves to venereal diseases outside of Often these were persons of low moral fibre who were apt to repeat•• psycholobic21 approach was required but how edly acquire venereal disoase.
it should b<;;s t be applied was uncertain. Health education aimod at the public had to overcome difficulties of language, tradition and education. The public had to be taught how the Various media had been used 4
venereal diseases could be avoided and cured.
in the Region, incluilil'1g' lectures, films, notices and pamphlets in Hong Kong where special cards had been designed for seamen and pregnant women. had been placed in the public lavatories in Australia; where state health depal'tments also issue pamphlets on VD, flipcharts, postHs and/or colour 6 2 slides had been used in Taiwan and Hong Kong,4 and in Korea a VD-campaign week had been organized.
Notices
..
Sound media (e.g. radio) was of value in illiterate
persons who could not be reached by other means. ,'/here less than 10% of the l population ~,ere literate, i.e. in Singapore and where there were many dialects, health education of the patients themselves by dord of mouth in the clinics was considered important. Not only did the public require health educ:ltion on venereal disease personnel) also. 32 Special training courses had been organized in Korea for doctors and health workers. Those bngaged in all branches of medicine needed constant reminders of the value of case-finding, contact tracing, the best available methods of treatment, and, above all, of the still present problems of venereal diseases. matters, but the medical profession (including para~edical
IIlPR/VDT/48 page 43 In planning venereal disease control programmes, local circumstances must
be taken into account.
Programmes must be planned ~ and not for the peoPle~
and the community as a whole must see the venereal disease control activities as 1eading towards goals in life which they value. 44 At the srune time the medical profession must regard the venereal diseases as other infectious diseases and the venereal disease prcgrammes flho\lld health programme. B.7 Availability of treatment 'lhe prinCiple that the provision of adequate facilities was the basis of effective venereal disease control was upheld. It was evident in SOme areas (e.g. Korea 6) that as inadequate facilities expanded, so did the numbers of venereal disease cases treated, and that until facilities were adequate, no coun try could have a proper lmowledge of the full ex ten t of its venereal disease problem. It was in the interest of public health to encourage the examination and, !
•
ce integrated
into the overall public
•
ifnecessar,y, the treatment of as many persons as possible suspected of having venereal disease. The provision of free treatment to pat~ents
of all national-
..
ities was one measure which for decades had received endorsement in many countries of the world, including some of the western Pacific Region, e.g. Australia; l and Singapore. That monetary expense was a deterrent in ensuring attendance 23 at the clinic was evident in data from Japan. It was shown that 46.8% of 271 defaulting patients had done so because of the medical expense and difficulty in finding time for treatment, other reasons.
•
33% from lack of knowledge, and 20.2% for
That the free treatment provided should also be confidential-
an essential part of the doctor-patient relationship - was also necessary. B.B Prostitution and venereal diseases
•
B.B.l
Toleration of prostitution
ll Some brothels were recognized in Cambodia and also in Laos 7 where the 2 police was a recent innovation. ::lome were licensed in Taiwan where special 36 "Tea rc.oms" had been established for the military forces. Isolated, more8 or-less tolerated brothels could be found in the Philippines and in certain parts of Aus tralia.
'.iIPR/VDT/48 page 44 10 Licensed brothels had been closed in Viet Nam in 1954 and in Korea 15 6 during 1955. In Japan where in September 1956 there were suspected to . 17 the brothels were officinlly closed on 1 i.pril be 150 000 prost~tutes, 1958, a few days after the Seminar was concluded, under the new Anti-Prostitution Law wl-uch bec2lTIe legally operative on that date, although its effects had been noted for some time. 8.8.2 Venereal disease in prostitutes ~si&
It was agreed th&t prostitutes in
were much more highly icfeoted Reported infection
. •
with venereal disease than the rest of the populaoion.
rates varied from under 10% to over 9O~8 but data could not be compared from country to country for various reasons but mainly because methods of reporting varied, particularly as to tho time during which the prostitutes were observed. If the period was long, an extremely large proportion would be affected. The younger prostitutes 28 were often those most likely to have early inVenereal-disease rates in
fections, although older prostitutes might have higher seropositivity rates for syphilis from accumulated late infections. facili ties. prostitutes tended to be higher in areas where there were inadequate medical i.part from syphilis and gonorrhoea, prostitutes were infected with the organisms of soft sore, lymphogranuloma vonereum, condylomata acuminata, and probably also with those of non-gonococcal urethritis and molluscum 28 contagiusum. In a series of 1970 prostitutes examined in Japan, 216 (10.96%) 19 street girl$ were 47.22% had gonorrhoea and 84 (4.26%) had latent syphilis. infected, chancroid. 42.21~
..
with gonorrhoea, 12.77% with latent syphilis,
and 0.55% with
VD rates in a large series of prostitutes arc given in Table VIII. ThBLE VIII
In Japan
28
7-19% of prostitutes had
posi~lve
serum tests for syphilis as Prostitutes were found
compared with less thm 2% in the general population.
to contract syphilis, gonorrhoea, soft sore and lymphogranuloma venereum in lO Viet Nam. Seropositivity rates amontrst prostitutes in Taiwan" ranged from 32 12.6 - 22.7%. In Korea it was calculated ilia t apprOximately 10% of prostitutes were infected (syphilis 3%, gonorrhoea 6%, and other VD 1%). In the Phil;pp;nes22. .~, ~ 1954-57 , 0 f 22 48 hostesses, w.itresses and female masseur attendants seen for tht first time, 3.1-3.4% were found to be infected
WPR/VDT/48 page 45 with gonorrhoea, of 905 female masseur attendants" and 9.2% in female dUEl to past y;aws. TABLE; lS~
were infected. SQm6
Serum tests for
syphilis were 3.9% positive in hostesse , 3.4% in waitresses, 5.2% in female of seropositivity was
•
The incidence of venereal diseases :in prostitutes in Taiwan is shown in Table IX. In summary,all forms of syphilis t i tutes in the mainland of China (at th
ad been reported in over 00% of prostime of the closure of the brothels in
1949), in 25-35% in the Philippines, an between 10-20% in Japan, Malaya and 28 Taiwan. Such data included also trea ed cases and were confused by the presence of an endemic treponematoSis in t e area. For gonorrhoea, an infection rate of China in 1949, and in Taiwan, and be 28 pore. In some the figures referred !
ceeding 50% was noted in the mainland een 10-30% in Japan, Malaya and Singaan anticipated examination (in which
concealment might be attempted)" others to surprise examinations which might be multiple or single. In some the diagno is was made by smear alone, in others by culture alone, or both • In a series of prostitutes in Jap
. ,;
, 0.5% had clinical soft sore, but many In Taiwan,34
carried suspicious bacteria in the vagi a. skin test for chancroid. High incidenc
48% had a positive
•
rates (28.7%) for lymphogranuloma 28 No clinical cases were, venereum were reported from the mainlan of China. 28 however, reported from a very largG ser es of prostitutes in Jap~ but the 34 Frei test was positive in 18.8% of pros tutes in Taiwan. As the "virus" of non-gonococcal utethri tis had not been isolated, it was
•
impossible to say whether a given pros ly high infection rate was likely. prostitutes but no exact data were
tute was infected or not" but a relativection with trichomomasis was common in ble. Condylomata later were found in
27.6% of a series of prostitutes in Tai an,28 and in 8.8% of 989 promiscuous women :in a more recently reported serie .34 It was evident that even in the antibiotic age, prostitutes were still ~eavily infected with venereal disease.
,JPR/VDT/48 page 46 8.8.3 Proportion of venereal di.seases caught from prosti tutss
In the majority of Asian countries the bulk (70-90%) of venereal disease was contracted from prostitutes. 29 This state of affairs ,/as fostered by local customs such as that in Japan which regarded ex:tra-marital intercourse with any but a prostitute as a sin. l ? For example, in ~ingapore12 of 3515 venereal infections in 1956, prostitutes were responsible for 3436 (97.7%), wives for 50, and 29 infections were contracted from other sources. In 1950 the figure was 96.8%.29 In Japan15 in 1955 some 72.5% of venereal infections in males were caught from prostitutes, only 0.6% from friends, 0.5% from marital intercourse, 6.6% from other sources, and in 19.8% the source was unknown. 68~6% of female infections were in prostitutes,
.,.
Some
In the Japanese Self-Defence
forcei~4 likewise over ~% of infections were caught from prostitutes and in Taiwan 2 most VD in males was contracted from such a source, ~sia
Thus, a different problem pertained in
from that in Europe, the
United states of America, and some other countries where only 5-34% of venereal infections were contracted in this fashion. 29 FIG. 11 8.8.4 Emphasis placed on venereal-disease control in a country where brothels have been abolished The comtating of prostitution was a social and not a medical rna tter, but the combating of venereal disease in prostitutes was an accepted responsibility of the health officer. iiboli tion of brothel prostitution meant that previously compulsory routine medical examination of prostitutes (as oppOSed to the examination of arrested persons) would also cease, and many prostitutes would become clandestine. 10 ,24,31 Prostitutes disguised themselves as hostesses, entertainers,e tc, - the taxilO ll dancers of Viet Nam and Cambodia for example. In Korca 6 the numbers of prostitutes attending the clinics fell considerably once it was no longer compulsory for them to do so.
.
On the other hand, providing steps were taken In S' 1ngapore12. 1n 1930
to find and troa t venereal diseases, the closure of brothels was usually ult~a ' t el Y f 0 11 owo d bY a fall' ~ VD prev al. ence, 3l By 1938, before the days of had declined by 66%. pen~cillin,
when the brothels were closed the VD admission rate was 33 per lOOO population. it had fallen to 15 per 1000. Syphilis
' I 1
WPR/VDT/48 page 47 the dissemination of venereal disease
The measures required to
minimiZ~ I
when prostitutes were absorved into t~e general cOlllllunity included: {l) the establishment of free treatment centres on a larger scale which facilities prostitute. could use without fear of the law, and which were so situated ~s to be easily available to them;
•
(2)
. • (3) (4)
the establishment of adequa e case-finding, especially contact l5 tracing activities so tha infected girls could be traced and treated when known to have cOlllllunity. ansmi tted venereal disease to the e training of suitable investigators;
This involved
health education of the pro ti tute (and the general public) to use such facilities; I
the viewing of the prostitut-e as any other member of the COlllllunity entitled to treatment, advite and help concerning all personal and 12 medical problems. 1
~ch !
measures could not be sucoe,sfully introduced without an increased If no financial provisions were made, a very serious situation 'I 1
budget.
l5
might arise.
•
Anti-prostitution laws were
gene~ally
aimed at the punishment of brothel
owners and the avoidance of annoyance [arising from solicitation in the streets, rather than against the prostitutes .
~emselves. i
A convenient method of COIJlllen-
cing health education of the prostitu¥ was by means of the spoken word in the lIIhile the rehabilitation of
•
~rostitutes was important, this was primarily a socio-economic and socio.-psjclrl.~trie matter rather than an immediate clinic. public h(.alth problem. Homes for the I rehabilitation of prostitutes existed in 12 a number of countries in the retion, .g. in S1ngapore and Viet Naml~ The of 171 prostitutes in Singapore are given in t he Table X.
•
results obtained in the rehabilitatio
•
TABIE[X In Japan, Women's Guidance Offices haie been establ:Lshed in all prefectures to
operate when the J.nti-Prostitution Lat came into effect. seen whether or not they would b e usei.
It remained to be
WPR/VDT/48 page 48 8.8.5 Routine medical examination of prostitutes
Periodic examination of prostitutes was practised on a voluntary basis " c~rcUl1lSin some countries (e.g. Singapore, 14 Hong Kong16) and un d er cer ta.J.n . Laos, ?.... . 36 and tances where brothels existed, e.g. ~ Camuo di a11 an d T~wan, upon arrest for vagrancy or soliciting, compulsory methods were used (e.g in 22 the PhiliPpines and Japan13 ). 'Ihere were many limitations in the routine examination of prostitutes. For the detection of gonorrhoea, these included the methods used in obtaining specimens, the staining methods employed, whether or not cultural methods were used in addition, the methods of culture employed" and the number of examinations made. In prostitutes, relatively frequent examiMany considered that a week Moreover, some prostitutes nations were required to detect gonorrhoea. and the timing of the examinations had to be related to the frequency of exposure. was a suitable interval for such examinations.
..
,
. ...
,
undergoing compulsory examinations attempted to conceal gonorrhoea by douching, self-medication or other methods, or to evade being put in the position of having to recoive such examinations. 31 .As regards frequency of serological tests for syphilis in prostitutes, in two areas Singapore and China (Taiwan) - they were perfo.nned once a month. In the Philippines where monthly tests had once been made, the interval had been extended to
.
3, 6 and latterly 12 months Owing to the low incidence of It was agreed that the interval at which routine serum If high. monthly tests were desirable, but
positive findings.
tests in prostitutes should be performed must depend on the prevalence of syphilis in the group concerned. this interval could be extended if the problem of syphilis was receding • .As many of the countries of the Western Pacific Region differed from those in Europe and the United states of J.merica insofar as in these Asian countries the great bulk of venereal disease cases was contracted from prostitutes, it was logical that special attention should be paid to this group. It was realized that the value of routine medical examination of prostitutes had its J1 limi ts but that the measure certainly could not be discarded as valueless. 22 8.8.6 Prophylaxis of venereal disease in prostitutes using antibiotics Data relating to a relatively closed prostitute community43(Table XI) had indicated that monthly injections of 2.4 mega units of benzathine peni-
•
viPR/VDT/4B page 49 cillin given to prostitutes would redice substantially (by approxilllately one half) the development of clinical inf1ctions (3.9% cumulative failure rate developing syphilis, as compared with 13.9% in controls). prostitutes themselves. As far as syphilis is concerned, therefore, the measure ~as certninly effective in protecting the Moreover, o~er data (from France- see Table XII) inIt seemed reasondicated that serum from prostitutes, ~ak:en 7-:21 days after such injections of benzathine penicillin, was immObili~g against T. pallidum. able therefore to surmise that, apart ifrom the benefit to the prostitutes themselves, the use of such methods IlIIlSt ap..so influence the syphilis rates in persons who cons _rt with them. TABLE.':> I
n
AND
F I
Possible disadvantages of
antibi~iC
prophylaxis in prostitutes included
possibili ties of inducing penicillin were rare, apart from occasional but
lergy31 Cal though reported instances of ck abscesses and local reactions which
penicillin reactions of any kind in pr sti tutes regularly receiving penicillin could be reduced in number if one and a half to two inch needles were used 25 From the standpoint of so as to taneous fat.
•
venereal disease control, the princip might only represent a small proportio better resul ts had been obtained in other parts of the world. titutes on the register, 93 cases bein total of 9463 prophylactic injections women during the year. peated visits males defaulters, 454 had moved to Mal In Hong Kong,
disadvantage of such methods was that of the prostitute communi~.
the number of available prostitutes re eiving regular treatment by such methods Somewhat . s respect in some parts of Asia than in for example, there were 1186 prosA
In Singapor ,14
added for the first time in 1957.
f penicillin were given to 6.38 of these tact-tracing organization was required 14 orted without being aontacted. Rethat the girls remained under treatOf 553 fe-
an efficient c
for, of these prostitutes,
mont (Fig.12) and only a fraction of t ose visited were secured.
a.
12
16
where prostitute
also attended voluntarily, regular patients visited returned for treatremainder were unable to be traced.
follow-up visits were also made. ment and 9.5% were unco-operative.
Some 1436 social visits were made in 1957, 0
6ff7 to suspected prostitutes. 19.4%
th
..vpR/VDT/48 page 50 The cost visit was HK$?11.16 16% of those attending did so far more than 4 Regular medical examinations were also made in Japan until 40 times a year. 5 the new law became effective in April 1958.
pe~
FIG. 12 The effects of the routine penicillin prophylaxis in prostitutes on the venereal disease situation of the community were difficult to evaluate and there was a need for the assembly of what data were available, both within and outside the Region.
or
particular interest was a n'ew approach to the problem made in Japanl?
whereby since 1952 experiments had been undertaken in prostitutes using penicillin and other antibiotics inserted deeply into the vagina after vaginal irrigation following the last sexual intercourse each night. Laboratol')" tests had sho'Wl1 significant concentration:; of JEnicillin in the vaginal cervix, and less so at the uterine orifice, 24 hours later, and to a lesser extent 48 hours later. Chlortetracycline and chloramphenicol had also been used in a similar Data presented, This approach manner, and likewise appeared to be of potential value.
indicated that such measures might reduce the incidence of both gonorrhoea and syphilis in the treated group as compared with controls. ~ting
lII1ght open new possibilities for dealing with the difficult problem of prevenereal disease in prostitutes and their consorts.
•
vVPR/VDT/48 9. Genelal SUMNJiliY
F I
page 51 CONCLUSIONS
The ~estern Pacific Region of th4 ~orld Health Organization covers a very wide area stretching almost from ithe Arct:i.c to the Antarctic md across the Pacific Ocean and includes manw i~lands, archipelagos and peninsulas. It embraces some 200 million persons 1nd a great variety of peoples with many differen t languages, cus toms, religon~
I I
and cultural backgrounds which to some
...
extent have influenced rent areas. presented.
th~ attitude t1 venereal disease problems in the diffeI
Several schools of thOUg1t in venereal disease control are re-
•
Nature and extent of the problem I I
I
In the Western Pacific Region of
I~
available information is limited in
most areas on the incidence and preva1jencc; of syphilis, gonorrhoea, non-gonococcal urethritis, chancroid, lymphog~anulOma venereum and granuloma inguinale. The methods of reporting these inf6ctifns vary widely and the indices used are often not comparable from one country ~o ano'ther. A study of the reported trends over a per'iod of time suggests,1 however, that the prevalence of syphilis has declined in several areas of the Rf>gion over the last ten years. o
~ some
countries it is now considered to be
OF
less public health signifiCance than preNon-'Venereally acquired syphilis
viously while it remains important in pthers.
in children ("endemic syphilis") has bren reported from islands of the south
Pacific, while endemic yaws is prevalept in the Philippines, Malaya, Cambodia, Laos and in a number of the Pacific Irlands.
'!he downward trend of syphilis har not been accompanied by a comparable fall in gonorrhoea. areas. '!his disease rem~s a public health problem in most Some areas have shown an
upwar~
trend in recent years.
In addition
non-gonococaal. urethritis (NGU) has apfarently assumed soraewhat greater importance than before. In at 1e ast ofe country it was reported from one
•
area that NGU has become more common tan gonorrhoea in the male. the prevalence of this disease, owing many countries of the Region. ~o
Generally
its confusion with gonorrhoea, may Ohancroid has declined in
be under-estimated rather than over-e1imated. I
:rPR/VDT/48
page 52 Notwithstanding the limitations of existing data the Seminar as a whole con:Iidered that venereal disease remained an important health problem in the Region. In one country sF£ cial survey techniques had been employed showing
that venereal infections were 6-10 times more frequent than when estimated on the basis of reported data. therefore recommends: (a) to that WHO explores with health administrations in the liestern Pacific the widely differing local conditions and circumstances (one-day or It was considered that the procurement of further data on the nature and extent of the problem was desirable and the Seminar
Region the possibility of carrying out venereal disease surveys sui ted
•
similar surveys, specialized or multiphasic sample surveys, special area, pilot or other surveys) so as to permit a more adequate appraisal of the emphasis which might be put in the planning of venereal disease control programmes in the future; (b)
that ante-natal serum testing be applied in the i1CH, venereal
disease and other services in the countries of the Region on the widest possible scale, not only for the purpose of case-finding and prevention of syphilis in the newborn but also to provide an index of syphilis in the different coun~ries
and areas, taking into account the limitations
. I
of such test in endemic treponematoses areas (yaws).
" " •
3.
Diagnosis, therapy and management Proper diagnosis and treatment of the patient is of basic importance in
management of venereal diseases. In Syphilis accurate diagnosiS by means of repeated darkfield examinations of genital sores and other suspicious lesions by properly trained personnel is required in the venereal disease clinics. laboratories qnd
•
Serological tests on the other
hand should be carried out by adequately trained staff in properly equipped a lew well-eq)lippedlaboratories are preferable to several It appears probable that more uniform serological procedures small ones se as to ensure a greater measure of uniformity in testing methods and procedures. are desirable in the Wes tern Pacific Region of ,IRO and that the crea tiOD of national serological reference laboratories furnishing standard antigens, supervising test performance and reactivity levels obtai. ned in peripheral
•
l-/Prt/VDT/48 page 53
laboratories was also suggested.
~temational serological reference centre at the disposal of national laborato~ centres should be established also in .lin
the ~estern Pacific Region of ~ as ~oon as possible.
National laboratories
in the Region may wish to take more a4vantage of the international reference preparations for cardiolipins, leci~ and" dried reactive sera now available through WO so as to standardize
thei~
own reagents and methods.
For the
appraisal of penicillin therapy in s~is quantitative serological techniques
... • •
are necessary • Long-acting penicillins are the of syphilis. tissues. of the treponemas to the treponemicid
I
eparations of choice in the treatment action of the ~rug
The time-dose relations . p determines the duration of the exposure in the blood and
Considerable variations hav been found between the duration of Such preparations should conInferior preparations to b e mades
penicillinaemia of long-acting preparJtions of different manufacture in different countries, particularly in the casle of Pi>H. will result in undue relapse rates •
form to the minimal international reqIrements ofWlll.
fO~Owing I
what appear to be adequate dosage
and do not allow a proper evaluation The Seminar recommends thatl (a)
~f the results of therapy
.. ,
Darkfield examinations be m1de on all genital sores wherever possible; of cardiolipin lecithin an tigens based
serological reagents and methOdSfe standardized in national serological reference laboratories by the us on international serological ref ence preparations; that quantitative serological techniques be adopte:; and that an international serological reference centre be establis ed in the Western Pacific Region under "1IilD auspices to promote further
erological work.
(b)
Repository penicillins, par~icularly PAM, which is the preparation 5~hiliS,
of choice in the treatment of
conform to minimal international
requirements so as to avoid unnegessary relapses and to make comparison of treatment results posssible. I
In gonorrhoea there are recogniZ~d limitations in the present techniques
for the diagnosis of the disease.
At Ithe same time there is clinical and i~ ~e
laboratory evidence that gonorrhoea of increasing dosages given trrough
becoming less susceptible, in spite year3, to penicillin treatment.
,lPR/VDT/4B page 54 iMhether this phenomenon depends on natural selection of strains of gonococci, increasing penicillin resistance, or both, has yet to be determined. The preparations and the dosage used, as well as the cure rates achieved, vary at the present time between differE'nt cOtIDtries in the :vestern racHic Region. But higher penicillin blood levels - and hence higher dosages - or the use of other preparations than the currently used long-acting penicillins - may well be required for wider use in the future. The continued use of repository penicillins (e.g. PilH) in gonorrhoea would only seem to be justified as long as the cure rates remain accept able, otherwise penicillin preparations providing higher peaks of penicillinaemia or other drugs, including the more cos tly tetracycline antibiotics may haue to be used. Some of the reported failures in gonorrhoea in males may be due to gonococcal urethritis. ~
.
,
This condition remains an important problem and little Further special ressar.ch in this field is rElquired.
advancement appears to have been made in recent years in determining the trno etiology of the condition.
There are no indications that gonorrhoea has increased in severity in spite of increased f&ilure ·rates to penicillin and complications are rarely seen. Opthalmia neonatorum is, however, encountered in some parts of the .. I
Region and tho need for further activities in this field in co-cperation with the 11CB programme appears necessary. The Seminar recommends that: (a) Further research be tIDdertaken to improve diagnos.tio methods in furthermore that an International
gonorrhoea as well as into the nature of the apparent lesseninng penicillin sensitivity of the gonococcus; Gonococcus Centre be established to take up these and similar problems.
•
4;
Penicillin reactions Experience has shown· over the last sevt:.ral years that allergic and ana•
pr..ylac-"ic reactions follOwing: pericillin therapy are nm, more frequenUy obse~ed than previously.
Severe reactions, however, remain relatively infrePerhaps severe
quent in relation to the enormous amotIDts of penicillin used..
reactions occur in less than 0.5 - 1.0 per cent of patients and the incidence of fatalities from anaphylactic shock may be less than 1 : 70 000 persons rece1ving penicillin for venereal diseases as found in an international survey
IiPR/VDT/48
page 55
of this pr oblem. previously used.
'l'his contrasts with Ithe 10-30 per cent. incidence of reactions
and the 0.03 per cent. mortality obtaifed with arsenic and bismuth therapy
Indications are that, whatever 1e reason, penicillin reactions are less frequent in venereal disease patients [than in those of other sectors of medicine. Many penicillin reactions and de1ths can probably be prevented by careful history-taking regarding previous al14rgy reactions (especially to pemcillin)
• •
and the availability for immediate us, of resuscitating drugs, All possible measures should be iken against the indiscriminate use and abuse of penicillin and other antibio ics and the use of these drugs without recognized clinical or public health in . cations should be discouraged. The value of sensitivity tests is limited although they are used in some countries. The Seminar recommends tha tl (a) &1 possible measures be
occurrence of reactions to to doctor's
pre~cription,
penic~llin
~en
to prevent as far as possible the (restriction of sale of the drug
its us, only on recognized clinical or public
•
health indication, discouragemenij of use in trivial conditions and of topical applications of the anti~iotiC). (b) All physicians administerin~ penicillin should take a careful·histoIY from patients regarding previous lallergy and there should be a tray of resuscitation drugs available treatment of the patient applied.
,
fO~
immediate use.
This done, it should be
considered that the doctor has t$en all possible practical steps in the provi~g I
that these measures are appropriately
5.
Venereal disease prevention and 9ontrol Effective venereal disease preve1tion and control depends on the provi-
sion of free and adequate facilities ~or diagnOSis and treatment, the use of
•
which should be encouraged by the community by means of case-finding through contact tracing and by investigation of special segments of the population and through health education.
WPR./VDT/48
page 56 klte-natal serum testing serves a quadruple function in detecting syphilis in young sexually activc adult women, in offering the opportunity to prevent syphilis in the child by the treatment of thE; mother with penicillin, by tho possibility of further epidemiological jnvcstigation in the family and by serving as an index of the syphilis state of the community. the ~estern
It is noted in
Pacific Region of
,ilia that ante-natal case-finding is in many The use of serotesting in
instances limited and that by no means all expectant mothers yet have the opportunity of receiving ante-natal serum tests. special groups at risk (e.g. seamen, and other migrant workers, military personnel, prostitutes, bar and tea-room eirls, etc.) may uncover venereal disease with less effort than, for example, when city employees, government officials and similar groups are chosen. Venereal diseases are often diseases of itinerants, especially with prostitution. seafarers~
and therefore pose a particular problem in seaports where it is usually linked The situation in one country therefore is affected by the ".s a ITDltually protective international measurc the Several mmi time situtation in another since venereal diseases, as most communicable diseases, recognize no frontiers. Brussels ./.greement of 1924 (o.d!ninistered by ,00 since 1948) provides for free treatment of seamen of all nationalities in port areas. to or have not ratified this Agreement and to do so as recommended by ,~Ha rr~ght
•
nations, including some in thevJestern Pacific Region, have not yet adhered profitably be encouraged in 1954.
•
Prostitution is universal and nc country has succeeded in suppressing it completely. Social reform has, however, led to the l~gal
abolition of
•
brothels in many countries with a view to preventing exploitation of women. Prostitutional intercourse is thus made more difficult to obtain and this in turn has in the long run tended to reduce the incidence of venereal diseases. Combating prostitution is a social not a medical responsibility but combating venereal diseases in prostitutes ( and other promiscuous women) and their consorts is part of the accepted responsibility of health administrations. Hany countries in the 1iestern Pacific Region have a problem differing from that of many other parts of the world in so far as 70-90 per cent. or more of venereal disease case are reported as being contracted from prostitutes, of whom 12-35 per cent. are infected with syp~is
or gonorrhoea or both.
iPR/VDT/48 page 57 The abolition of brothels, and the rehabilitation and integration of prostitutes into the general community, offer definite problems in venereal disease control. protected. h wider outlook is necessary if the community is to be ProFree and confidential treatment must be available to all.
miscuous women as well as any other members of the community should, by health education at all levels, be encouraged to utilize such facilities for early diagnosis and treatment. Epidemiological case-finding must be used. scr~ening
• •
Venereal disease in the community (from which also the prostitute becomes infected) must be uncovered as far as possible by procedures (e.g. ante-natal blood testing and testing of special groups). disease control programme when brothels are being closed. without increased expenditure. The Seminu- recommends that: (a) The principle of free treatment of venereal disease be accepted ~estern
Emphasis on free These broader
treatment, case-finding and hbalth education is essential in the venereal functions of the venereal disease service can hardly meet the new conditions
by all countries also of the
Pacific Region and that in circums-
tances where brothels are being abolished the possibility of dissemination of venereal disease in the community should be met by (i) the creation of adequate diagnos.tic and treatment facH ties for all; (ii) establishment of an adequate case-finding systems (including contact tracing);
•
(iii) development of suitable health education and other techniques to assure the attendance at the venereal disease clinics of persons who constitute the major foci of these diseases. (b) More countries in the :iestern Pacific Region adhere to the Brussels
Agreement of 1924 regarding treatment facilities for se2farers in major
• 6.
ports. WHO-sponsored Venereal Disease Seminar in the Western PaCific Region ~t
the conclusion of the Seminar it was agreed that the Seminar had most
adequately served the functions intended am in view of this fact, The Seminar recommended that: A further Venereal Disease Seminar be .sponsored.. by JHO in .the western PaCific Region in approximately five years l time when the status of the many changing and complex venereal disease problems could again be reviewed.
ilPR/VDT/48 page 58
Nwnter 1. 2.
Title Venereal Diseases in Singapore Venereal-disease Control in Taiwan, China Venereal Disease in Australia An Appraisal of Venereal Disease in Hong Kong
Author L.. u.
iIPR/VDT/l llffi/VDT/2 1*,R/VDT/3 'WPR/VDT/4 ;ifh/VDT/5 ;{tR/VDT/6 IIPR/VDT/7 .lPR/VDT/8
Ram
T. H. Wong H. C. Johnston G. M. Thomson
3. 4. 5. 6. 7.
Venereal Disease problem in Japan Venereal Disease Problem in Korea The Venereal Diseases in Laos The Problem of Venereal Diseases in the Philippines and the Progress in Venereal-di;;;ease Control over the last 10 Years Venereal Diseases in French Polynesia Venereal Diseases in Viet Nam Venereal Diseases in Cambodia Venereal-disease Control in Ports Port Venereal-disease Control in Japan Contact Investigation General Consideration for the Contact Investigation Hethods in Venerealdisease Case-finding in Japan Some Aspects of the Epidemiolobical Investigation of Venereal Diseases in Hong Kong The Role of Prostitutes in the Spread of Venereal Diseases and 11ethods to Control the Spread of Venereal Diseases by these Prostitutes in Japan
Y. Tanami C. ~i.
Lee
H. Bandhavong T. L. Yusay
8.
9. 10~
WPR/VDT/9 VlPh/VDT/10 "WEI. /VDT/ll 'WPI1./VDT/12 ~1JPR/VDT/13
Louis Begon Nguyen-Hun-Phiem &
Nguyen.Van-Ut
11. 12. 13. 14. 15.
Hun-Sareth & Heas Khan L. H. Ram
. • •
R.
~noda
.lPh/VDT/14 IVPtt/VDT/l5
i'l. Hiyairi S. Ebihara &
T. Sakurai G. 11.
16.
.-Jffi /VDT/16
'Ihomstrl
17.
WPR/VDT/17
T. Qhno & K. Kato
,/PR/VDT/48 page 59
Number 18. -IIiPR/VDT/18
Title Penicillin-Resistant Gonorrhoea in Hong Kong and some Observations on .Antibiotic Resistant Non-Gonococcal Urethritis Venereal-disease Clinic and Administrative Activi ties at the FijiJni Hospital (Kanagawa Prefectural Govt~) Diagnostic and Therapeutic Problems in Early Syphilis and Other Foms of Syphilis Some Aspects of Pre-Natal Syphilis in the
Author G. 1"1. 'lhomSCl'l
19. ~
-1PH./VDT/19
Y. Onoda & H. Yoshida K. Kitamura
• •
20. 21. 22.
.1PR/VDT/20
,.t'h /VDT/21 -WIl./VDT/22
T. L. Yusay L. H. Ibarra
Philippines Prevalence of Gonorrhoea and .:3yphilis J>mOng Hostesses, ,/a1tresses, Female Uassuer Attendants and Female Vagrants ExamLned in the l'1anila Rapid Treatment Centre, Manila Health Dept., City of l'1anila
23.
WIR /VDT/23
Administrative and statistical Studies in the . K. Ohara Field of Venereal-disease Control in the Tokyo l~tropolitan Area Venereal DiSeases Among the Self-Defence Forces
24.
WIt, /VDT/24
•
F. Ishidate T. Veld Lieut. Col. R. Hamada 11ajor T.Hiyazaki Cdr.K. Veda Lieut. Col. K Hirashima ~~jor T.Kishimoto
25.
wPR/VDT/25
Diagnostic and Therapeutic Problems in Early and Other Forms of 6yphilis, Taiwan Venereal-disease Control Programme A Review of the Present Status of the Laboratory Aspects of Venereal-disease Control Non-Gonococcal. Urethritis ~GU) Prosti tution and Venereal Diseases I. Venereal Diseases Amcng ProS". itutes in Asia
,l.
FrlShlich
26.
~/VDT/26
{>I. G. Simpson
A. Harris J. C. Cutler
~
27.
WIlt /VDT/27 (:(II T/VD T/1o $
R. 3ti.noda It. It. ,dllcox
28. (WlR /VDT/28
vJPtt./VDT/48 page «J Number 29. (WPR/VDT/29 (INT/VDT/lo6 Title Prostitution and Venereal Diseases II. Venereal Diseases in Prostitutes in Asias A comparison with France, the United Kingdom and the United states of America Author R. R. Willcox
JO. 31. 32.
(vlPR/VDT/JO (IN T/VDT/lo9 {MiPri./VDT/31 (INT/VDT/110 VlPR/VDT/32
R. R. Willcox Protitution and Venereal Diseases Social Considerations of Prostitution III. Prostitution and Venereal Diseases IV. Medical "Control" of Prostitutes A Report on the Present Venereal-dl.sease Control Methods used in Korea R. R. Willcox Y. K. Cha
..
33. WPR/VDT/33 34. WPR/VDT/34
Seroreactivity of Blood in City Employees A. P. Roda & Pre-natal and Pre-marital Population Groups Z. A. Pilapil The Epidemiology and Control of Venereal Diseases Among the Prostitutes and Promiscuous l,fomen in Taiwan The Etiology of Non-Gonococcal Urethritis Civil and Mill tary Co-opera tion in the Control of Venereal Diseases in Taiwan The Treatment of Non-Gonococcal Urethritis The .Serodiagnosis of Syphilis in Japan T. H. Wong & P. N. Wang
35.· 36. 37. 38.
WPrt./VDT/35 WPR/VDT/36 (iJffi/VDT/37 (INT/VDT/104 WPR/VDT/38
R.R. Willcox . ·W. N.. Chang & w. Frtfulich R. R. Willcox K. Nakamura R. Murata & T. Tomizawa
.
39.
(WPR/VDT/39 (lNT/VDT/lOl (,JPIt/VDT/40 {IN T/VDT/102 (WPR/VDT/4l (INT/VDT/103
Clinical Problems in the Antibiotic R. R. Willcox Treatment of Gonorrhoea in the Male I. Reduced Efficacy of Repositor,y Penicillins Clinical Problems in the Antibiotic R. R. Willcox Treatment of Gonorrhoea in the Male II. Treatmen t Failures in Ethnic Minorities Clinical Problems in the Antibiotic Treatment of Gonorrhoea in the Male III. Treatment other than with Repository Penicillins
40.
•
41.
R. R. Willcox
*Ph/VDT48 page 61 Number 4~.
Title Prevention of Venereal Infections I. A Wider Outlook £J:ID'.ontion or Venereal Infections II. Prohylaxis and Preventive Treatment Some Socio-Cultural and Psychological
Author T. Guthe T. Guthe
(WPR/VDT/4..: (m T/VDT/l07 'IlPR/VDT/43 !ilPR/VDT/44
43. 44. ~
Considerations in the Control of Venereal Disease 45. ViPR/VDT/45 Venereal Disease in the Maternal and Child Health Field
L. L. Keyes & D. R. Huggins E. Wakamatso
•
46. Gjestland, T. (1955) Acta derm.-venereol. (Stockh.), 35, Supp1. 34.
.. 47. 48. 49.
(The Oslo Study of untreated syphilis: An epidemiologic investigation of the natural course of the syphilitic . in£eotion based on are-study, of the 'Boeck-Brunsgaaid material) Willcox, R. R. & Guthe, T. (1956) WlI)
Working document 'II'rl0/VDT/224
Benson, W. W. , Foltz, B. J. & Graeber, F. O. (1957) Sight-sav. Rev. 2'1, 13-16 Oregcn lUth Bull. 1956, 34, 4 Ormsby, H. L. (1957) ,lm&r. J. NurSing, 57, 1174-1175 Guthe, T., Ids&, O. & Willcox, R. R. (1958) Bull. Wld. Hlth Org. 19, 427-501 Willcox, R. R., Guthe, T. & Idstte O. (1957) tmpublished working document WHO/VDT/245 Idstse, O. et ale (1954) Bull. 'Mld Hlth Org. !Q, 509 Coleman, M. & 31e8&1, B. B. (1955) J. Allergy, 26, 253
.,
50. 51. 52.
..
53. 54.
•
wm/VDT48 page 62 REPCh T OF dOl.KING GIDUP NO. I
JlNNEX I
on l'li:.THOD... FOh l1EJl.JU...IlW Tllli PREVilll.NCE. Al'IJD/On INCIDhl,GL OF VEN.c.REJ.L DISEASES WITH PARTICUL-.t. r-..E.FE.,ENCE TO ThL APPLICABILITY O} SUCH METHOD:> TO 'IHL COWTn.IE.j OF TH1 '1JE..,T1i1N PaCIFIC Rl!..GION OF wHO
The working group met three times and was attended as follows: First session, 19 March 1958, 17.15-19.00: Dr. Miyairi, Dr. D. R. Thomson, Dr. Yamamoto. Dr. FrBhlich, Dr. Johnston, Dr. Soda (Deputy Director,
Institute of Public Health) and Hr. Fuchiwaki (Statistician, Department of Health and Welfare Statistics, Ministr,y of Health and Welfare) also attended. Second seSSion, 21 March 1958, 14.00-17.00: Niyairi, Dr. Phiem, Dr. D. Thomson, Dr. Yamamoto. Dr. G. Thomson attended part of the session. Third session, 25 March 1958, 14.00-16.00: Dr. Huggins, Dr. Johnston, Dr. Cha, Dr. Johnston, Dr. Dr. Huggins and ,
•
Dr. itiyairi, Dr. Phiem, Dr. D. Thomson, Dr. Yamamoto. 1. At the first session The working group heard a description of the methods used in undertaking various forms of health surveys in Japan. 1.1 The one day survey This was originally designed as a one week survey with the purpose of ascertaining the prevalence of sickness, the use made of medical facilities, and the cost of these. Information on venereal diseases w~s~obtained
•
invene~
Cidentally and no attempt was made to undertake special examinations for real disease in these surveys.
It was found later that a better response could •
be obtained by limiting the survey to one day, and a preliminar,y study showed that days in the middle of the week were close to the average in regard to attendance. The period of the year varied from one year to another and it is believed The surthat in Japan there is no seasonal variation in attendance of patients. as an institution with more than 20 beds), and clinics.
veys were undertaken on a previously stratified random sample of hospitals (defibed: One tenth of all hospitals, one fiftieth of all clini\:s, and one two-hundredth of all dental clinics
WPR/VDT/48 page 63 .Annex I were selected in each stratwn. The method used was to distribute questiom;.aires '.lhe planning was ~ried
to each participating unit (see Annexes 1,2 and 3). one month for each survey, .health centres.
out centrally and required the work of fin professional people 1'ull-time for The questionnaires were distributed from the Ministry of Health and Welfare to the prefectural governments; through these to the The directors of health centres were made responsible for the of questionnaires to and from the institutions The Preparatory meetings to outline the purpose of the distribution and collection
•
and private physicians.
survey and the procedures were held beforehand at the health centres. Statistical Council, and adopted by the Government. not only a centr~'l
surveys were undertaken under a special ordinance proposed by the National Such surveys require corps of statistical advisers, ar.d an extensive network The response in Japan has been high,
of peripheral points, but also that a reasonably accurate census exist both of population and of medical facilities. since the completing of questionnaires was compulsory but no assessment can be made of the quality of the data obtained.~ 1.2 Trial investigations in pilot areas A more intensive investigation was undertaken in a pilot area of the prevalence of gonorrhoea. Hyogo prefecture near Kobe was selected because Seven out of it was kn. wn that the health centre staff would co-operate. gy~aecologists.
46 health centres were selected, and each obtained data from about three Smears were taken and stained with methylene blue from all Thus out of 326 smears It is thought that the method could be women attending these physicians on a certain dc\y. obtained, 2.8% showed gonococci.
extended to include serological examination for syphilis, but further trials in the same area have to be undertaken before the method could be used for
a nationally representative sample.
For th.LS type of survey also a fairly
we1l-developed statistical department is necessary.
a Details of the one day survey metnod have been presented by Dr. Soda to the fifth session of the WHO Expert Committee on Health statistics, in 1956. See document WJ:IJ/HS/79, 20 November 1956
iPF./VlJT/48
page 64 Annex I
1.3
Sickness surveys 'lhese are carried out in random samples of population by lay investiga-
tors and students to determine ho,. many people are sick at a certain point of time and what proportion of these are receiving medical attention. These surveys have not provided any information about specific disease, such as venereal disease, but the figures can be used for correlation with the estimates of sickness derived from the one day and other surveys. Each ~ea contained 50 households. one person. 1.4 Other investigations Other investigations, such as mass examinations, surveys of m~ tal patients and of crippled children, blood pressure surveys were also discussed, as were the inadequacies of monthly returns from hospitals and of notification of infectious disease, the latter having become yet more unsatisfactory since the suppression of free postal priviledges for notification by the financial authorities. 2. The second session This was devoted to a review of other methods of gathering information on incidence and prevalence of venereal disease and of comparing trends in such data over a number of years. It was genereally agreed that continuing serological investigation of pregnant women through ante-natal clinics, hospitals, phys.icians and mid,lives was a promising activity which also permitted curative and preventive action to be t~{en.
For these
sickness surveys 200 areas representing a sample of 1/1700 were selected. Ten households could be investigated by
•
,
The advantages of a micro-test which would Other groups wh.J.ch might
only require blood from a pricked finger tip were stressed, in that at present blood could not be taken by rnidnves in some areas. profitably be examinees, were, prostitutes, the armed forces (at the time of induction or release or both), prisoners, candidates for government service, students, blood donors. In genereal it was not thought that the yield from
serological examination of schoolchildren would uustify the effort and expmse. The lack of co-operation of physiCians was also discussed and it was felt that the question of effort versus remuneration was one of the practical problems in
'tlPri./VDT/48 page 65 Annex I
obtaining good co-operation. It was stressed that there should be better co-ordination between the venereal disease control programme proper and other health services, particularly 1'1CH, and that it was the task of the venereal disease programme to provice facilities such as diagnoaU c laboratories.
3.
The third session This consisted of a discussion on the information that ens might wish to
obta. n from a one day survey of venereal disease, assWDing that such a survey would be possible in a given country.. It was agreed that in order to ensure The following data were It was recognized the maximum of co-operation from institutions and physicians, the information requested should be kept to the bare essentials. deemed to represent the minimum that could be requested.
that in some cases it might be desired to obtain more detailed information for other purposes than just ascertaining a prevalence ratio:
• I. PATIENTS
1. 2.
Sex
Age i'larital status Occupation Address (district) Syphilis (a) (b) (c) (d) (e) (f) primary secondary early latent late latent late congenital
3. 4.
5. 1.
II.
DIAGNOSIS
~
2. 3. III. NEIiIi/OLD GASES
Gonorrhoea Other venersal diseases
WPR/VDT/48 page 66
PATIENT SCHEDUIES USED IN JAPAN IN ONE DAY HEALTH SURVEY Patient Schedule (Patient Card) Designated Statistics No. 66 (13 July 1955)
Institution No. (1) (2) (4)
I Male Female (3)
Prefecture
Name of patient Sex
Date of birl:.h
..
Name of disease or injury ,
(5)
Kind of service
In-patient (1 new; 2 carried from past) Out-patient first visit (3 hospital or clinic visit; 4 home visit by a phySician or a dentist) Out-patient revisit (5 hospital or clinic visit; 6 home visit by a physician or a den\ist)
• All paid by patient Soc ial health insurance (insured) 3. Seamen's insurance (insured) 4. Mutual assistance association (insured) 5. Day labourer's health insurance (insured) 6. SOCial health insurance (dependent) 7. Seamen's insurance (dependent) 8. Mutual assistance association (dependent) 9. Day labourer's health insurance (dependent)
1. 2.
I
(6)
Method of payment
1. Worlanen's canpensation insurance 2. TB Control law II 3. National health insurance 4. Daily life security law (medical care aid) 5. others Remarks
.. Inesignated Statistics No. 66] Institution No. "'atient
•
~
'.
{'
,.
..
PATIENT SCHEDULE (DISCHlRGE PATIENT CARD) JUNE 1-30 1955
'1 liame of Disease 01 In.iury Date of 110St~ta1i-
Prefecture Date of Reason for Discharge 1. Recovery 2. Becoming I better Method of Payment All IJaid by pa tient l1ealth insurance (insured) 1\ (dependent) " 3. Seamen's insurance (insured) 1\ (dependent) " 4. i1utual assistance association (insured) Mutual assistance association (dependent) 5. Day labourer heal th insurance (insured) Day labourer healt h insurance (dependent) 2. l.
No.
Date of Sex Birth
-
za
~on
Dischar~€
M
1
3. Death
11
4. Other
1. 1rJorkmen t s compensation insurance 2. TB centrol law II 3. National health insurance 4. Daily life security law(medical care) 5. Others
2
3 • • • •
~
:~ t
""~
~§-
IiPR/VDT/4B pal:'e 68 Annex I
I Designated Statistics No. 66\
Patient Schedule (Institution Card) July 13, 1955 Prefecture
IInstitution No. 1) 2)
Kind of institution Ownership
1. hospital 1. 2. 3~
2. general clinic 3. dental clinic
4. 5. 6. 7. 8.
National (Ministry of Welfare) National (Other) Prefectural Ci ty, town and village Red Cross Saiseikai Agricultural association Social insurance no speciality internal respiratory digestive surgical orthopaedic obstetrical & gynaecological ophthalmological 2.
9. Juridical person far public utili W 10. Juridical person of medical care 11. Company 12. Other juridical pereon 13. Private secondary mentioned 14. Educational organ
•
3) Specialities
I
1. 1. 2. 3. 1. 2. 3. 4.
dental
3.
radiological
n
4. circulatory 5. paediatric 6. mental & nervous 5. oto-rhinola~ngOlogkEl 6. bronohi & oesophagus 7. (skin & urinary) B. venereal 9. anal-surgical dermatological & urological Communicable disease others Total
III
•
4}
Number of beds legally permitted
Mental
TB
I
.
,{fR/VDT/48 page 69 Jmnex I Patient Schedule (Institution Card) continued
5)
Personnel
Physician
Dentist
Pharmacist
Midwife Assistant nurse & Nurse
Full- Part- Full- Parttime time time time
Other technician
Clerk
Others
Student nurse midwife
Intern
6)
Number of patients at July 13
New inpatient
I' ! • 7)
Inpatient carried from past
New outpatient
Revisit outpatient
Total
I
•
Case Number of Medical examination, prevent.i va inoculation and venereal examination Number of discharged inpatients in July
8)
Remarks
WPR/VDT/48 page '70
ilNNEXII HINIHAL TlllihAPY FOh THE INDIVIDUAL PATIl:.HT wITh VEi'l:t..hl:.hL .iYrHlLIS Several participants of the to the above subject. ~O
Regional Seminar for the Western
I'acific have requested further in forma tion in regard to practices relating
In this connexion the participants are referred to the considerations of the fourth session of the WHO Expert Committee on Venereal Infections and Treponematoses published in the \iliO Technical Report Series No. 63, 3.2.2.1 pages 19-21 and .Annex 4, page 54 of the English version and pages 21-22 and 59 of the French version, which has been distributed to all participants. Specimen syphilis treatment schedules with procaine penicillin G in oil with 2% aluminum monostaarate (P.hl!) for the individual clinic patient with primary and with secondary syphilis are contained in Appendix 1 to this memorandum. Participants may also be interested in the therapy practices in other countries,and reference is made to the world-wide study by WHO published in the wHO Bulletin, 1954, 10, 579-617, which is entirely devoted to syphilis and contains also major reviews on the laboratory basis, rational and outcome of various forms of therapy. In the United states of JUnerica penicillin has been used in syphilis " ~
I I
t I I I II \ I
most a'{tensively and for the longest period.
The diagnosis, treatment and
management practices of the venereal-disease clinics used throughout the country are contained in "l'lanagement of Venereal Disease", publication No. 327, 1955 of the United states Public Health Service Division of Special Health Services, Jiashington, D. C. For information of the participants the treatment schedules therein recommended are reproduced in Appendix 2 to this memorandum.
•
WPR/VDT/48 page 71
Annex II Appe.ldix 1
SPECIMEN SYPHILIS TREATMENT SCHEDULES WITH PAM FOR THE INDIVIDUlJ. CLINIC PATIENT This schedule refers to PAH meeting WHO minimum requirements as to blood level duration2 Primary Syphilis Mega-units of PAM to be given on the following days 1 2.4 -1.2 1~2 I \
Total I
2
3
4
5
6
7
8
9
10 -
II
12
13
1.2 1.2 1.2 1.2 1.2 1.2
.. - 1.2 0.6 0.6 0.6 0.6 0 .. 6 - 0.6 0.3 0.3 0.3 0.3 0.3 0.3 0.3 - - -
0.6 .
-
>
.'
0.3 0.3
.
- -
2.4
0.6 0.3 0.3
-
-
0.3
--
-Secondar,r ~hilis
• 1 t..8 2,4 ~;.4
•
2
Mega-units of PAM to be given on the following days Total 8 9 10 II : 12 16 3 4 5 6 7 17 13 15 14 j
.
1.2 1.2 ...
?.4 ,2.4 2.~
..
1.2 - - - - - 1.2 2.4 0.6 0.6 0.6 0.6 2.4 0.6 - 0.6 - 0.6 - 0.6 2.4 - - 0.6 0.6 -' 0.6 2.4 0.3 0.3 0.3 0.3 0.3 0.3 0.3 0.3 2.4 - 0.3 - 0.3 - 0.3 - 0.3 - 0.: -
1.2 - 1.2 1.2 ... 1.2
-
2.4
. .
4.8
0.6
0.3
-
0.3
-
0.3
\ad Hlth
arg. techno Rep. Ser.~ 54
,;
2wJ.d HUh Org. techno Rep. Sere 63, 55 Annex 5
WPR/VDT/4S page 72
AnnaxII Appendix 2 THE SCHEDULES GIVEN ARE PREDICATED ON THE USE OF PAM MEETING WHO MINIMUM REQUIREMENTS At'JD BENZATHINE PENICILLIN WHERE THE BLOOD DURATION IEVEL OF BENZATHINE PENICILLIN IS SIMILAR TO THAT OF PAM WHEN USINJ HALF THE DOSE OF BENZATHINE PENICILLIN
Syphilis - Treatment Suggested schedules: Primary and secondary
PAM .. 4 800 000 units (1st injection, 2 400 000;
2nd and .3rd
..
injections, 1 200 000 each; injection
given at 2- to 4-day intervals)
or Benzathine penicillin G - 2 400 000 units in a Single
Latent, cardiovascular, gummatous, and osseous PAM ..
4 800 000 units (1st injection, 2 400 000; 2nd and 3rd given at 2- to 4-day intervals)
injections, 1 200 000 each; Neurosyphilis
PAM .. 10 800 000 units (900 000 every 24 hours for 12 doses)
•
Early congenital (less than 2 years) PAM - 1 500 000 units (150 000 every 24 hours for 10 doses)
Late congenital Same as for comparable manifestations of acquired syphilis
lPublication 327, 1955, United States Department of Health, Education and Welfare, Public Health Service, Venereal Disease Programme, Washington 25, D. C. Zwtd Hlth Org. techno Rep. Sere
~ 55
Wfft/VDT/48
page 73 ANNEX III REPORT OF ,.Qn.!CLJG GROUP NO. 2
on REACTION.;) TO PE'JUCILLIN
The working group cons:i.sted of: Dr. R. Pierron (observer). 1. Nature!)Ild extent of the problem
Dr. 'Ii. FrlJhli.ch (Chairman); Dr. L. M.
Ibarraj Dr. Y. Onoda; Dr. G. H. Thomson; Dr. N. V. Uti Dr •. Th. Guthe;
Wi th the increasing use of penicillin over the past 15 years it has
been shown that this antibiotic is antigeniC and that allergic and anaphylactic reactions, including death, may occur.
Such reactions are now beConsider~t,
lieved to be more frequent than before and are more frequen t in urban than in rural areas, because of lesser use of penicillin in the latter.
ing the widespread use and misuse of penicillin serious reactions
how-
ever, be considered to be relatively few and a fatality rate of only l' ?O 000 !
was recorded in an intema tiona! survey conducted by WHO ccvering more than 600 000 persons treated in venereal disease clinics in 17 countries. Toxic reactions to. penicillin are practically unknown in man and Herxheimer reactions in syphilis occur as with any other treponemacidal drug. Microbiogenic effects include the generel phenomena of secondary overgrc,.· .. h by less sensitive or insensitive micro-organisms and the creation of resistant bacterial strains. Recently a lessened sensitivity of the gonococcua to penicillin has been described among the microbiogenic effects of this antibiotic. This note is confused to major considerations in regard to allergiC and anaphylactice reactions to penicillin •
•
Prevention In order to lessen the wide abuse of penicillin it should only be avail-
able from druggists on doctors' prescription.
Topical application should
particularly be discouraged, because experience has shown that application to skin and mucous membranes (troches, drops, sprays, oin1lnents, etc. ) result
in a high degree of sensitization.
WPR/VDT/48 page 74 Annex III The use of penicillin should be confined to clinical and public health indications • .! Repeated penicillin applications over a long period is more apt to create sensitization than the use of a single large dose or foreshortened treatment schedules. There are also hidden sources of penicillin sensitization such as milk from penicillin treated cows. 1-1o:,e important from the practical point of view Penicillin syringes used also is the fact that syringes and needles still contain penicillin in antigeniC quantity following sterilization by boiling. for other purposes may thus be the cause of unintentional sensitization in medical practice. 3. Information On appropriate occasions the medical professions should take the oppor-
tuniry to enlighten members of the public about the serious reactions which may follow indiscriminate use of penicillin.
At both post-graduate and undergraduate teaching the same principles should be followed. 4. 4.1 Diagnosis of existing sensitivity Anamnesis The diagnosiS of existing penicillin sersitization depends on the taking of an exact history and on skin tests. I t is pointed out that these tests a re
.. •
not reliable and therefore attention should be given to: (a) (b) a history of any possible previous con tact with penicillin in any form or application; the occurence of any subjective reactions which may have followed previous penicillin medication. as important. The history can provide important indications for existing sensitization and is therefore considered Experience has shwon that severe and fatal reactions could have been prevented if a more detailed history had been taken •
.! The use of penicillin in cosmetics should be prohibited.
Annex III
For the self-protection of the physician it is recommendable that the history as well as the results of any diagnostic test performed be recorded by the doctor himself.
4.2 ~
Cutaneous testing methods Cutaneous testing methods are not reliable in drug allergy, in fact no
testing procedure is known which would permit the certain diagnosis of drug • allergy and this holds also true for penicillin hypersensi tivi ty. 5. The treatment of reactions to penicillin Before giving penicillin, or recollllllending an injection of penicillin to te administered, it should be the responsibility of the physician to ensure that the following drugs are available for iIlmediate use. ensure their sterility and potency. 5... 1 !
It is also advised that
those drugs be kept in a tray or in a box, and that routine care be used to
DrugS and equipment considered essential
.
(1)
1 in 1000 solution of adrenalin hydrochloride ampoules of nikethamide (coramine) - two (2) an antihistamine preparation for intramuscular injection (e.g. Benadryl, Piriton or Chlortrlmeton) 2 x 2 ml sYringes and hypodermic needles
(2) '3) (4)
..
5.2
Drugs also recommended if locally available (1) (2) Cortisone for intramuscular or a sui table hydrocortisone preparation for intravenou. injection Aminophyllin up to 0.5 g r13r I.V.I. in slow i.v. injections.
5.3
Procedure IlIIII.ediately on appearance of signs of a reaction, the patient should be
laid down fiat.
From 0.3 to 1.0 cc (5 to 15 minims) of adrenalin. show.d be
given into the arm, followed by 2.0 cc of coramine.
WI' R/lJDT/48 page 76 Annex III
If immediate improvement is not obtained, or the patient's condition deteriorates, then the adrenalin should be repeated, or cortisone (25-100 mg) given intramuscularly or hydrocortisone hemisuccinate given intravenously. Other recognized therapy for severe shock should be instituted and where possible the patient should be admitted to hospital. In cases shOwing angio-neurotic oedema, urticaria or conjunctival congestion, the antihistaminic preparation should be given by intramuscular or intravenous injection. Where coughing, dyspnoea, respiratory distress and substantial discomfort are pronounced, a slow intravenous injection of 0.25 to 0.5 gm of aminophylline should be administered.~ ..
Should the private physiciaJlumddoctors working in out-patient departments not have available the items listed und6r 5 above, they might be considered to ha'lre made inadequate provision for treatment, and conversely, if the drugs were available and they had carried out the Jrocedures outline above, it should be concluded that they had taken every available precaution wi thin their power to avert an accident.
~ Recently penicillinase has become available commercially for injection. Little experience is available with this type o£ preparation in anaphylaxi!3.,; ~o"rtd the body of penicillin an intramuscular injection of 800 OOO"Units of penicillinase is recommended by the manufacturers as soon as signs of penicillin reaction appear. This type of preparation might possibly be included in the treatment of severe penicillin reactions in the future.
.iPt:'./VDT/48 page 7? Annex
III
Testing Methods 1. 1.1 Methods in use Scratch tests have the advantage of not being dangerous as the
reactions are lilllited to the skin l but are of a low level of sensitivity. The method is inexpensive as the test can be perfonned with small amounts !.
of crystalline penicillin;
the necessary amount can be taken out of the
vial without spoiling the rest of the ccntents. 1.2 Intradermal tests are l if performed with increasing quantities of This test is expensive
antigen l more apt to permit the diagnosis of hypersensitivity, but are dangerous l because they may provoke general reaction. as one vial of penicillin has to be dissolved and this solution is not stable; besides this l sterile glassware (measures) and relatively large amounts of sterile distilled water are required. The emergency kit mentioned (see 5) has to be on hand if intradermal penicillin tests are p:lrfonned. 1.3 Opthalmic tests are probably more sensitive than scratch tests and are The conjunctival congeation which follows a positive test is rather Keratitis following a positive
inexpensive as they can be performed with small amounts of crystalline penicillin. uncomfortable for the patient and an adrenaline or antihistaminic solution should be on hand to limit the reaction. ophtha.lrllic reaction has been described in rare instances. 1.4 Nasal and inhalation tests should not be considered because of a
possible systemic reaction. 1.5 Oral tests. Limited work has been carried out in Japan using oral Further e:;q>erience in this
tablets in testing for penicillin 8ensitivity.
field is requested before an evaluation can be made. 2. 2.1 Procedures Scratch test: crystalline pEilicillin powder is applied to the cleaned
skin of the forearm and a drop of sterile water added and mi.xed l or a drop of a crystalline p!
nicillin G solution in water (50 000 or 100 000 units per ml) one or two scratches of 1 cm length are then made through
are applied directly;
the drop with a suitable instrument ( e. g. sharp needle) at a depth insufficient
WPR/VDT/48 page 78 .Annex III
to cause bleeding.
To exclude pseudoreaction caused by a non-specific
irritability of the skin (dermatographia) a similar scratch is made in the other forearm wi th an instrument which had never been in contact with penicillin.
2.2
Intradermal tests: the quantity injected intradermally should never The
exceed 0.1 ml (if suitable syringes are at hand not more than 0.05 ml). tion of 500 units per ml).
first injection should not exceed 50 units of penicillin (0.1 ml of a soluIf the patient does not react to the quantity injected within 10 to 15 minutes the quantity injected can be raised to 100, 200, 500 and finally 1000 units within intervals of 10 to 15 minutes. Oily penicillin preparations oannot be used for intradermal tests.
•
2.3
Ophthalmic tests:
some crystals of crystalline penicillin G powder
are applied to the conjunctiva or two to three drops of a penicillin solution of 100 000 units per ml are used. 2.4 All tests are read or judged after 20 minutes.
~R/VDT/48
page 79
LIST OF TABLES Table Table !
I.
Blood testing of expectant mothers in Singapore Death rates from syphilis in Japan InfantUe death rate due to syphilis in Hong Kong Foetal deaths due to syphilis in Japan Outcome of pregnancy and effects of adequate preventive treawnt in the pregnant syphilitic mother Treatment results in syphilis with different therapy Application in syphilis of preventive measures based on natural history Clinical venereal disease in prostitutes in Japan Venereal disease in prostitutes and promiscuous women in Ta,iwan Rasul ts of rehabUi tat:ion of prosti tutes in Singapore Incidence of infectious syphilis in prostitutes !l1Inobilization of T. pallidum by sera from prostitutes receiving penicillin
II. III.
Table TAble Table Table Table Table Table
"-
IV. V• VI. VII.
.. 1.
VIII.
IX. X•
•
..
Table Table Table
XI. XII.
..
WFR/VDT/413 page 80 TABLE I. BLOOD TESTING OF E1,PECT1.NT MOTHERS IN SINGAPORE
Year 1951" 11952 I
No. tested 1.363 1784 4708 5727 5616 61413
SerO] ositivi~ Percent~es In In ! , Primiparae Multiparae t I
Total 5.4 3,8 4.4 4.3 2,8 1.4
3~O
8,2
j,53
1954
I
jl955 11956 , , I
2.6 3,2 1,8 2,5 2.6
! . I • , ,
I
5.5 4.9 4~8
I
I
2,9 1.2
I , i,
I
i
TABLE II. DEATH RATES FROM SYPHILIS IN JAPAN Death Rate per 100 000 Treated 6,7 6,2 5,5 51'0 4.2 3,8 3.0 .3.0
Year 1949 1950 1951 1952 1953 1954 1955 1956
S,yphilis Patients 5501
• •
5176 4630 4265 3692 .3.394 2882 2750
..
WFR/FDT/48 page 81.
TABLE III.
INFJ.NTlLE DEJ..TH RATE DUE TO SYPHILIS IN HONG KONG4 Infant Mortality Rate due to ~phi1is per 100 000 Live Births 27.74 16.67 9,,27 8.40 7,,73 7.24
~
• ~
Year
Live Births
I I I
Deaths from Syphilis
I I
. :.!
I
I 68500 71 9'76 75 544 83317 90 511 96746 19 12 7 7 7 7
11951 1952
11953 11954 I
! 1955 I
; 1956
• TABLE IV. ~
FOETAL DEATHS DUE TO SYPHILIS IN JAP.AN 45 Deaths due to Syphilis 1 150 783 497 .398 .302 234
,
.. ~
Year
I ! 1 I
,
Foetal Deaths
%due to ~hi1is
1950 1951 1952 1953 1954 1955
149 080 158 034 151338 145 200 l44 593 144 654*
0.77 0,49 0.33 0 .. 27 0,21 0.16
.
* 46 845 spontaneous and 97 809 artificial.
WPR/VDT/48 page 82
TABLE V. OUTCOME OF ffiEGNANCY AND EFFECT OF ADEQUATE ffiEVENTIVE TREATMENT IN THE ffiIDNi.NT SYPHILITIC MOTHER ( Ingraham, 1951 )
i
Outcome
I r0rmal full-term living infant ILiving syphilitic infant
Non' Syphilitic ·mothers
Untreated I Mothers treated for early syphilis syphilitic, I mothers r-" lAs and Bi i Penicillin I
.' .,
86.3
18.2 40.9
91.4 2.2 0,7 1.9 0.0 3.4 0.4
94.0 1.1 0.4 0.2 0.9 2.3 1.1 •
Premat ure non-syphilitic! I infant IFul.l-term infant i iPremature infant
9.0 0.5 1.7 0.5 2.1
2.] 1.8
.
I ,
U.8 18.2 6.8
lStillborn, full-term Premature (miscarriage) ; ,
All figures expressed as percentages. The material comprises more than 10 000 deliveries at the Philadelphia General Hospital, Pennsylvania, United States of America. (Ingraham, N. R. (1951) Acta derm.-venereol. (Stockh.), 31, Supple 24, 69)
•
•
..
•
.,
;
,.
,'
.
[0'
~
;0
I.
TABLE VI. COMPARISON OF PENICILLIN ALON!!" WITH PENICILLIN + ARSENOXIDE AND BISMUTHIN THE TREATMENT OF SECONDARY SY PHILIS -----
Penicillin alone Cases re-neated abservation period (months) Number of cases observed Cases not re -neated Seropositive Cumulative per---".-, Number celltage -~.--
Penicillin + arsenoxide and bism., th Cases re -neated Cases not re-treated
-_..
-
, Seronegative I
..
-'
N~ml:cr
% 0.• 1 0.6 ' 0.3 , 1..3 1.. 6 1.'1 1.4 0.9 1.5 0.9 0.6 0.6 0.9 0.5 0.8 0.0 0.6 0.8 0.5 0.3 0.4 0.0 0.0
0/0
Number
"/0 0.9 6.4 22.1 37.4 50.4 56.5 80.4 64.8 67.6 70.1 72.1 74.2 76.0 'l7.0 7'1.5 78.9 '79.8 SO.9 Bl.O SO.8 80.0 ) '79.1 80.7
Number . of cases observed
, , Number;
Seropositive Cumulativ4_ percentage Number
Seronegative
Of.
"/0 99.0. 91.1 73.0 56.9 41.8 31.6 24.7 20.4 . 18.3 l'l.'7 15.8 12.2. 10.1 7.3 4.8 3.3 3.0 2.'1 2.0 2.1 1.5 1.9 1.6 "
Number
0/0
1 2 3 4 5 6 7 8 9 JO 11 12 15 18 21 24 30 36 42 48 54 80 72
6'79 675 674 671 669 666 664 661 859 654 650 648 635 614 595 554 504 474 438 382 250 157 71
1 4 2 9 1"
0.1 0.7
lJ
9 6 10 6 4 4 6 3 5
.
3 4 2 1 1
-
1.0 2.3 3.9 5.6 '1.0 7.9 9.4 10.3 10.9 11.5 12.4 12.9 13.7 13.7 14.3 15.1 15.6 15.9 16.3 16.3 16.3
6'72 627 518 404 305 252 216 182 Itl 128 110 92 73 61
51 40 29 18 14 12 9 7 2
99.0 92.9 : 76.9 I 60.2 ' 45.6 · 37.9 32.5 27.5 _ 22.9 · 19.6 , 16.9 14.2 ' 11.5 9.9 I , 8.6 '1.2 i 5.8 3.8 3.2 ; 3.1 I 3.6 I • 4.5 2.8
6 43 WI 251 337 376
.'1 42'1 446 458 469 481 482 473 461 437 402 383 355 309 200 124 57
: '
I : j
292 291 289 . 288 285 285 284 264 . 264 282 2'18 2'78 27'1 273 271 269 264 25'1 245
,-
1
3 4 5 '1 1 2 2 2 '1 4 2 4 1 .
-
I ; ' I
256 : 204 , : 159 64 -"
1 1
1
; 0.0 0.0 0.3 , 1. 0 1.4 : 1. 8 2.5 0.4 0,7 . 0.7 0.7 , ~.5 ' 1.4 0.7 1.5 0.4 0.0 0.0 0.4 0.4 0.0 0.8 0.0
0.0 0.0 0.3 1.3 2.7 4.5 '1.0 7.4 8.1 8.8 9.5 12.0 13.4 14.1 15.6 1tl.O 16.0 16.0 16.4 16.8 16.8 17.4 17.4 ~>.
2f9 265 211 164 U9 90 '10 58 52 50 44 34
28 20 13 9 8 '1 5 5 3 3 1 • .
3 26 '77 120 158 182 194 206 209 207 208 211 212 214 216 217 214 209 200 191 167 128 52
1.0 8.9 26.6 41. 7 55.5 63.9 68.3 72.2 73.6 73.5 74.7 '75.8 76.5 '78.5 '79.6 80.6. Bl.O Bl.3 Bl.5 81.0 81. 7. SO. 8 Bl.O
l~ t
..
• The total dosage ranged from 1 500 000 to 4 800 000 unill. with an average dosage of 3 200 000 unill - The total dosage ranged from 1 200 000 to 4 800 000 unill. with an average dosage of 2 800 000 unill Reproduced from Sbafer. J. K. UsUtou. L. J. " Price. E. V. (1954) Bull. WId HIm 0Ig •• ~ 563
,
I
;~ ?? Ol
wPR/VlYI'/48 page 84 TABLE VII. APPLICJ.TION IN SYPHILIS OF ffiEVENTIVE BASED ON NATURAL HISTORY*
~.SURES
prevention I !-------------T,--------------------------------------~--------------· Sex education, preparation General improveiAvoidance of IHealth promotion I disease-producing for marriage, pre-marital ment of socio-ecoI I organisms by and pre-natal examinations ,nomic conditionsj · as part of general medical 'recreational facii Ihealth education examinations I
LeVel of
Agent
Host
Environment
I. , ! Specifip.
i
I I
in hygiene
lli ties welfare , programmes
...
i 1'rotection
: Prophylaxis I chemical : mechanical, and : chemotherapeutic
!
,. .. . ' adequate treatI~arly dl.agnos;l.s : ment to destroy and treatment j T. pallidum
iPre-natal serologic iSuppression of camexaminations, avoidance of :mercialized prostiipromiscuity ltution; precaution : in handling disI charges of syphiilitic infants Cau'tion in laborato,ry workers . Case-finding for early !Educational media !syphilis; advice on inidemonstrating 'fectiousness; immediate 'urgency for early land adequate treatment; :diagnosisj adequcontact investigation; ; ate diagnostic : examination of infants of itreatment and syphilitic mothers at !contact facili: birth and regularly for 3 : ties I :months; routine exam! iination of cerebrospinal , fluid
•
•
ID~sab~~ty,
f limitation:
I i i ,
!
: Treatment to destroy T. ! pallidum in 1 brain of those with paresis
I
Case-finding for latent syphilis and for early ! signs of late syphilisj adoquate examination of • heart and central nervous : systemj routine examination of cerebrospinal ,flv;dj adequate treatment
I I
Educational media ; demonstrating ;effects of nonItreatmentj provi,sion for low-cost 'treatment faCilities for compli,cated syphilis of iworking conditions of the disabledj the car- ' jdiac patient, the 'paralYsed, the blind
rh&bilitation :
,Preparation for blindness in primary optic atrophy; rehabilitation of the blind and of patients : with tabes, paresis, and i advanced cardiovascular : disease
I iImprovement
* Reproduced
from Leavell & Clark (1957) Textbook of Preventive Medicine
WPR/VDl'/48 page
85
TABLE VIII.
CLINICAL VENEREAL DISEJ.SE IN PROSTITUTES IN JIJ'AN28
Year
! ; I
Collective Prostitutes
Separated Prostitutes with VD No. Examined 24 ?l7
i
, No. Examined
J % infected ,
j : I
% infected with VD I 36.1 44.2 36,0 22.0 14.5 14.6 i l
i 1950 I
1948 1949
..
1951 11952 I ! 1953 !
,
I , ,
! I I
I I
20 738 60 176 37 776 49 658 22 369 53 ~O
, !
13.. 6 11.9 18.8 19.7 16.0 15.1
I TABLE IX.
:
39 785 56 1]2 69 612 68 297 ~ 298
i j !
! I
, j
I
VENEREAL DISEASE IN m.OSTITUTES AND mOMISCUOUS WOMEN IN T.t.IWAN34
(Licensed prostitutes, female entertainers, bar girls, tea-room girls, hotel maids) !
•
I
I I
Examined
~
iT ainan survey 1957 !Keelung survey 1957 IKaohsiung survey 1957: Taipeh survey 1958 Totals
277 198 4J.4 100
!
j%sero1% 1 G.C positive ' for syphilis plus
~
% with J
J genital. , ulcer
13.3 17.1 12.6 8.0 13.0
t 24.5 36.5 27.2 46.0 30.4
2.5 2.0 1.9 2.0 2.1
I
% with condylomata acuminata
989 TABLE X.
8.3 11.0 10.0 3.0 8.8
RESULTS OF REHi.BILITATION OF PROSTITUTES IN SINC1'J'Om:12
I
In the home ! Discharged to guardians ! Married Engaged as domestic helpers Unemployed
IEngaged as dance hostesses or i Returned to prostitution
Change of residence to Federation of Malqya bar attendants
33 53 23 14 13 ? 13 16
172
TJ\BLE
.a43 Control group (clinical cases treated) Sero-reactors Number examined I
INCIDEI\!CE ore INFECTIOUS SYPHILIS IN PROSTITUTES
'@~
~~ , Primar,y, secondar,y lesiom+
Number of months after be~innin~ of
Test group (monthly" maintenance" doses -;:- ) Sera-reactors Number examined Prima r,y , secondary lesions+
+=" ex>
trial 0 1 2 3 4
Per cent. CumuNumber Per,cent. Number of total lative per cent. 14 13 12 12 11
I 1 er cent. CumuNumber Per cent. Number of total lative per cent. 23 22 20 19 22 21 20 21 22 21 20
32
31 29
43.7 41.9 41.4 40.G 39.3 37.9 34.5 36.7 31.0 28.6 25.9 28.6 20.7 I
1 u 0 0
0.0 0.0 0.0
0.0
54 53 51 49 51 50 49 50 49 49 50 49 50
42.5 41.5 39.2 38.8 43.1 42.0
0
3.8 2.0 0.0 0.0 2.0 0.0 0.0
3.8 5.8 5.8 5.8 7.8 7.8 7.8 9.8 9.8 9.8 13.9 11.9
I
i
2 1 0
o.L 0.0 0.0 0.0 0.0
3U 28 29 29 .
0 Q ()
0.0
0 1 0 0
,
I
5 6
11
O.v 0.0 0.0 Li.O
10 II
40.8 42.0 44.9 42.9 40.0 44.9 44.0
7 8 9 10 II
30 29 28 27
v lJ
v.e 0.0 0.0 0.0 3.9 3.9
9 8
1 0 0 2 0
2.0 0.0 0.0 4.1 0.0
0 0 1 0
O.l .
7 8
0.0 3.9 0.0
12
, I ,
28 29
22 22
6
2.4 mega units'benzathine penicillin G given preventively at monthly medical examimtions + Clinical cases were treated with 4.8 mega units PAM in one session
*
•
,
......
~
,I/O
WPR/vm/48 page 87 TABLE XII. 43 IMMOBILIU,TION OF T. PALLIDUM BY SER.A FROM
PROSTITUl'RS
RECEIVING PENICILLIN:
PBItCENTl.GE IMMOBILIZATIaJ
OBTAINED IN A SUSPENSION 1:10 WITH 5-10 MILLION ORGANISMS*
Treponemicidal action of ser'lml in prostitutes having received 2.4 mega units of benzathine penicillin i.m. No. of days after
Persons 1
injection • 7
2 100,( i
3
4
I 5
I
6 10~
7 : 100% , : 100
I
8
14 21
, 100% I 100 • l
, lC>Qt; , loa;t
100 100
96 74
28
I
!
100
54
32
25
! 74
1100 !9l
100
96 71 50
100 65
1190 if!?
* 5~ immobilization in this dilution corresponds probab~ to 100% in the circulating blood. •
Qouted from Durel, P. & Hardy, N. (1957) Rev. Hyg. Med. soo.
21 219
.. •
..
WPR/VDT/48 page 88 LIST OF FIGURES
F~.
• 1 2
l-!ap of western Pacific Region of .:/HO Venereal disease incidence in Japan Venereal disease in New South -,"ales, Awtralia Incidence of syphiliS in the Philippines Death rates due to syphilis in Japan Na:turaJ. history of acquired syphilis Incidence of gonorrhoea in the Philippines Incidence of gonococcal ophthalmia and infantile syphilis in Singapore Comparison of venereal disease incidence in ground and naval self-defence forces in Japan Contacts of United States Merchant ¥mrine Source of venereal disease in Japan Case holding visits to prostitutes in Singapore
Fig. Fig. Fig. Fig. Fig. Fig. Fig. Fig. Fig. Fig. Fig.
3 4
5 6 7 S
9
10 11
12
•
II i ,
i
vn ..... . ........ ,. '
o .... ...... ::::::. :>:: .,', .. ', ...... -::~> '<:/ »>::~::
z
... -: ...... .
• &..
~ UJ ~ fJ)
u
I.L. «
u
..... .;.: ::: .... :::<-~:-:- ~>:
:::>.
-::::.<:::::-:>: ....... .:<-::~:::::>:
fL
",,:;, J I,e"'"!.!'
UJ ~
•
...
•
FIG.2 VENEREAL DISEASE INCIDENCE IN JAPAN Annual Change in Case Rates for Venereal Diseases (per 100000 population)
1000
800 600 400 ~
1000 800 600 400
200
200
• 100 80 60 40 .2 c
100 80
--
60
-"",
40
CHANCROIU
'3 Q, a Q,
0 20
"
"
..........
c 0
20 ..!! ~
~
Q.
0
Q.
8 8 ~
0
10 8
10 8 6
0 0 0 0 0
!. 6 c.: " ~
.. ~
Q.
4
,
1! 4 a:: "
2
2
0.8 06 0.4
1 0.8 0.6 0.4
02
0.2
0.1
0.1
1947
1948
1949 1950
1951
1952
1953
1954
1955
1956 WHO 8318
FIG.4 INCIDENCE OF SYPHILIS IN THE PHILIPPINES
2000...-----------------------------,2000
1750 ~~~-~~----------------------__i17~ \ ~
,.
,.)\
\
1500 ~----~------------------------~1500
\
PROVINCIAL AND SOCIAL HYGIENE CLINICS
•
u .!
:I 1250 ~--------~~--------------------------------------~12~:I a a
..
\ \
.. .. u VI
1 . 1000 ~----~------~----------------------------------------~10oo1 "0 "0
j
j E
" 750 z
~~--------~~----------~----~~------------------~ CITY OF MANILA
" ''---' ~
7~:i
E
500
•
250 O~
__
~
____ 1949
~
__
~
____ 1951
__
~~
___ L_ _ _ _L __ _ 1954
~ _ _ _ _~ _ _~
o WHO 83U
1948
1950
1952
1953
1955
1956
1957
FIG. 5 DEATH RATES DUE TO SYPHILIS IN JAPAN
10 8 6 4 PARALYSIS
10
8 ALL SYPHILIS
6
~
2
•
'" '
~' ~
-Ii
/
..... _------ CONGENITAL SYPHILIS
....
...
-; 0.8
.2 0
co
OTHER SYI'HILIS
... ~
"'-!.
~ _:"..
OTHER SYPHILIS OF THE CENTRAL HERYO"S SYSTEM
-- -- --IIIII!!I!.---- ~--------= ........... ~---.
---
4
2
8.
0.6
~
i ~
OA
8.
~ 0.2
-L''f",
\
LOCOMOTOR ATAXIA
---
=---..!:
/
1
0.8 ~
" ~ ~
--~--
~-~~-
ANEU;IYSM OF tHE AORTA AND AORTITIS DUE TO SYPHILIS
0.1 0.08 !
~ ~ ~ ~
-..
-.....
0.6
0.4 a
§
5. a 0.:
0.2 ~
0.06 INFANT SYPHILIS (PER 1 000
LIYEBIRT~
~
0.1 0.08
0.06
0.04
0.04
• 0.02 0.02
... ..,
0.0 1
I
I
I
I
.1 1951 1952
J 1953
.1 1954
.1 1955
J 1956
0.01 WHO 8}87
1947
1948
1949
1950
• •
•
l
,
•
''I,
01
•
'
.
Fig. 6 NATURAL HISTORY OF ACQUIRED SYPHILIS
PREPATHOGENIC PERIOD
PERIOD OF PATHOGENESIS IN MAN AGENT. HOST INTERACTION
FCII'cel operating to bring agent
and host ,-,,"<: Secondary sV!'hi lis
AGENT ELEMENTS: R.qulr.ment. for propagation Prerequisite moist ....
},
, \
Clinical'
Infectious ... loPI.
Cardiovascular svphills
HOST ELEMENTS: Sa.ual habit.. promiscuity Sex .ciucation Proximity of contact Us. 01 prophylaxis Personality d.v.loprMnt
, j,,,'\ , , , \
iE
\
,
10·15"
ENVIRONMENTAL ELEMENTS: Cllmot., mol,tur., humidity Famllv Instability Income, houllng Recreational focllitl •• Community mealur•• : R• .,...lIlon of proatltution
Availability of treatment Co ••. finding: Epidemiological (case to contact)
, ,,, ,,,,, ----- ,~ \ \ \ \ W .. k, to months Early Syphilis Inf.ction
ECI"ly lat.nt syphilis LATENCY
\
4 year.
I
5·10 v_s
,, , ,
La .. La..nt Svphllis
25·35"
10.15 yoars La .. Svphilis Spontaneul Cur•
15· 25 yo«s +
Sy,"matlc blood· testing (groups at risk)
~~~~""~ ~.:~~:~~;~.~~.~,.~~~
) Diaabillty Limitatian
.. .. .. ..
..
...... 25· 35"
'~i""'r""""";r'!'m""'''''''''''''''''';~~''n;'-''
LEVELS OF
PREVENTION WItO 8}711-
F.IG. 7 INCIDENCE OF GONORRHOEA IN THE PHILIPPINES
O~
__
~
____ 1949
~
__
~
____ 1951
~
__
~~
__- L_ _ _ _L -__ 1954 1955
~____~__~
o WHO 8322
1948
1950
1952
1953
1956
1957
..
•
FIG.8 INCIDENCE OF GONOCOCCAL OPHTHALMIA AND INFANTILE SYPHILIS IN SINGAPORE 1950 - 1960
•
F.IG.9 COMPARISON OF VEI'EREAL DISEASE II'CIDENCE IN GROUND AND NAVAL SELF -DEFENCE FORCES IN JAPAN
~r------------------------------------------------------------.60
~
• 20 r-----------------------------------~~--------------------~20
.t
...
. c: 0 ~
MSD
8 0
810 r-------------------------------------------~~~--------~10 ~
..
, ". F' ,,----,-_.,.,.......... ASDF
~ ~
0::
0
8.
~'.' •.'
8~ 6.2 0::
~
c
NATIONAL SURVEY. MINISTRY OF HEALTH
c
~
4
•
2~----------------------~~~~=---------J
2
...
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957 WHO '832~
• •
•
'.
,I,
r
i
•
,oo
,~
It ..
to
.'...
Fi., 10 CO~TACTS OF US MERCHANT MARINE, PERCEHTACE DISTRIBUTION OF 4,364 CONTACTS OBT... lHED FROM 2,426 INFECTED MERCHIo.HT SEAMENBY PORT' OF EXPOSURE, JUNE -NOVeMBER 1951 "
PI.l1 ISLANDS-.
*Unidentlfiabl. ports of .eamen's contacts are excluded. **Dato supplied by courtesy of US Public ~.alth SeNice-. Department of Health, Education, and Welfare.
WI10 8375
•
'.
.1'>
I
.c
~
...
.-.: . r ,I
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,
.
FIG. 11 SOURCE OF VENEREAL DISEASE IN JAPAN
INFECTIOUS SOURCES OF MALE PATIEH1S
INFECTIOUS SOURCES OF FEMo\LE PATIENTS INa.LOING PROSTITUTES
Otlwrs 11.5"
Wifes 0.4"-~
Friends 0.5
................. , ............. .... . ............... .......... ..... ...... . ..................................... .......... .......... .... ........... . '" ................................ . .......... .... , .... , .... . , ........................ . ..... , .... .......... ' ••• •••• , •••••••••• 0 ••••••••••••••••• ,
Prostitutes 71.0 %
Partner. of prastitutes 72.1 % WHO a32~
'"
• .11
II
i
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,...
.~
, r « ..
(
.
FIG. 12 CASE. HOLDn... VISITS TO PROSTITUTES IN SINGAPORE MONTHLY CONTACT • PA05T1TUTES .Iua~ 1952 December 1956
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I sol.
Number 01 viii"
mNumber of o.tendone.. ••• • I •• • • IISO
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