THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION · NOVEMBER 1986 healthier sex Cover : Sexual love- but is there a serpent in the Garden of Eden? Design by Peter Davies IX ISSN 0043-8502 World Health is the official illustrated magazine of the World Health Organization . Editor: John Bland Deputy Editor: Christiane Viedma This Month's Theme Editor: Catherine Dasen Art Editor: Peter Davies News Page Editor: Peter Ozorio World Health appears ten times a year in English, French, German, Portuguese, Russian and Spanish, and four times a year in Arabic and Farsi. Articles and photographs not copyrighted may be rep ro- duced provided credit is given to the World Health Organization . Signed articles do not necessarily reflect WHO's views. World Health, WHO. Av. Appia, 1211 Geneva 27, Switzerland . Contents Healthier sex by George Antal. 2 Syphilis and gonorrhoea have company by A. 0 Osoba and B. 0. Ogunbanjo . 5 The social environment by Maggie Jones . . . . . . . . . . . . . . . . . 8 AIDS: a global challenge by Jonathan Mann . .. . The keys to STD control Prevention and detection 12 16-17 by Gavin Hart . . . . . . . . . . . . . . . . . . . . 18 Can we really control STD's? by Fernando Zacarias . . . . . . . . . . . . 20 Putting babies at risk by And re Meheus .. Drug resistance by Herbert Nsanze . .......... . .. . Endemic treponematoses 22 24 by Georges Causse . . . . . . . . . 26 Stable families-healthy children by Pal Veres . . 28 News Page . 30 2 W oRLD HEALTH, November 1986 Healthier sex WHO is seeking simplified ways of controlling sexually transmitted diseases so that transmission is significantly reduced and people may enjoy sex without risking harmful consequences to their health What the sexually transmitted diseases (STDs) have in com-mon is that they are transmit- ted predominantly by sexual contact; but there are at least 20 causative agents , and they include bacteria, viruses , protozoa , yeast and even arthropods (parasites). In addition to the five classic "venereal diseases" which include syphilis and gonorrhoea, an increasing number of disease conditions have been found to be spread from one person to another by sexual contact and are often referred to as the " sec- ond generation" of STDs. They in- clude conditions such as nongonococ- cal urethritis (which is often caused by the virus-like bacterium, Chlamydia trachomatis ) , genital herpes , genital warts , hepatitis B and others. The most recent addition to this group of diseases is the acquired immunodeficiency syndrome (AIDS) which , because of its high mortality and its rapid spread throughout the world , has become the most talked- about STD in recent years. Many of these second generation diseases have been known for years but their extent , method of transmission and clinical consequences are only now appreci- ated because of advances in diagnostic technology or because of changes in sex practices in some groups. A wide array of interrelated demo- graphical , social-behavioural and medical factors have contributed to the present worldwide epidemic of STDs. While it is possible to identify some important contributory causes , it may often be beyond our ability to influence some of them. In developed countries, and even more so in developing countries , the Electron-micrograph of Treponema pal- lidum-the agent that causes syphilis. Photo WHOIR. Phill ips W oRLD HEALTH , November 1986 by George Antal age composition of the population has undergone significant changes, so that the proportion of people in the age- groups which are the most sexually active, and which account for most of the infected cases , has greatly in- creased. Changes in sexual behaviour and attitudes in the form of greater sexual liberty or new sexual patterns , increased access to modern birth con- trol methods, and social changes as a consequence of urbanisation, indus- trialisation and ease of travel are all factors which have contributed to a significant increase in the number of new STD cases in recent years. Accurate information on the inci- dence of STDs in countries is difficult to obtain from official disease reports, not only because of under-reporting but also because only some of the classic venereal diseases are notifiable, and the rest are ignored. In spite of these restrictions, sexually transmitted diseases are now the most common group of notifiable infectious diseases in many countries. Information based on field studies . and sample surveys indicates particularly high rates of STD in most parts of Africa , East Asia and Latin America. In fact, various studies in Africa found that between two and ten per cent of pregnant women are infected with gonorrhoea. In one African country, between four and ten per cent of all patients attend- ing dispensaries , health centres and hospitals came on account of STDs. In another country, some 12 per cent of pregnant women had a positive syphilis test , whether they lived in towns or the countryside . The emergence of AIDS and the fear of acquiring this potentially dead- ly infection has led to a marked de- cline in promiscuity among population groups particularly exposed to AIDS infection, and this may reverse the increasing trend of other STDs as well. It is important to note that the STD organisms mentioned above can also be transmitted in ways other than by sexual contact. For instance , the infec- tion can be transmitted during preg- nancy or at birth from the infected mother to the infant. This is the case with syphilis, gonorrhoea, herpes, AIDS and other infections , and may result in abortions , infant death or significant ill-health for the infant (nerve damage, eye or lung infection and so on). Non-sexual transmission of syphilis, AIDS or hepatitis B may also occur through infected blood , blood products or unsterilised instruments. Most countries recognise these in- fections as major public health prob- lems not only on account of their frequency but because of their impact on maternal and infant health, and their economic cost in terms of health care expenditure, lost productivity and their social consequences . Women and children bear an inordinate share of the STD burden. An estimated eight to 20 per cent of women with gonococcal or chlamydial infection will develop, if left untreated, a spread of their infection to the uterus and the tubes, including the adjoining tissues, leading to a pelvic inflammatory dis- ease (PID) and the possible develop- ment of a tuba-ovarian abscess. In the United States, nearly a quarter of a million women are sent to hospital for PID and half of them have to undergo surgical procedures. Reports from African countries in- dicate that 20 to 40 per cent of all gynaecological admissions are for PID. The associated infection of the fallopian tubes may lead to their par- tial or complete occlusion, which in turn may cause ectopic pregnancy or sterility. In fact , 13 per cent of women will become sterile after a single episode of PID , 36 per cent after two 3 Healthier sex infections and 75 per cent after three infections. This devastating complica- tion can be prevented by providing treatment early in the course of dis- ease. However, the diseases which cause PID are often .asymptomatic ; more than half of the women are unaware of their infection and may not even seek early treatment. Special control measures are necessary to identify infected women and give them the benefit of treatment. In areas where high infertility rates coincide with those of high STD trans- mission , fallopian tubal blockage and the consequences of epididymitis are the major causes of male and female infertility. Hospital admissions for pel- vic inflammatory disease as well as for ectopic pregnancy- a leading cause of maternal mortality-increased by more than 50 per cent over a six-year period in a South-East Asian country. Some STD microbes disseminate in the body and cause a generalised dis- ease which may be severe; this will impose heavy demands on an already overburdened health care service. Syphilis and AIDS are well-known systemic sexually transmitted diseases. Maternal infections with STD agents can lead to complications of pregnancy, as well as transmission or damage to the unborn child (as in the case of congenital syphilis). Infection of the birth canal with gonococci or chlamydiae can cause a severe eye infection in newborn babies, particu- larly in countries where the appli- cation of eye prophylaxis has been abandoned. Moreover cervical cancer is increas- ing, particularly among the younger age groups. There is growing evidence of an association between this cancer and infections with certain strains of a sexually transmitted human wart virus. Antibiotic resistance Increasing resistance to antibiotics has become a worldwide problem in the treatment of some STDs. The amount of penicillin required to cure gonorrhoea has increased more than a hundred-fold since this antibiotic was first introduced for the treatment of this condition. The recent rapid devel- opment of gonococcal and chancroid strains completely or partially resistant to a variety of antibiotics has made the established low-cost treatment regi- mens virtually ineffective, and new therapies are being developed. The 4 continued, indiscriminate use of anti- biotics by a large number of misin- formed physicians and health workers not only favours the development of further resistant strains but also results in more treatment failures and longer periods of infectivity and disease transmission , and of complications. This problem is particularly pro- nounced in developing countries where , in the absence of laboratory facilities, treatment failures may go undetected. This increases the risk of complications developing. The avail- able health care service is often inade- U JUUIU 1111111 UUUI IIIUlU UUIUIU IH 11 Clinic for sexually transmitted diseases in the Philippines. Photo WHO/Zafar quate to deal with these diseases , care is very expensive, and the stigma at- tached to STDs inhibits people from seeking professional help. Conse- quently a large number of patients resort to self-medication, or obtain treatment from non-medically qual- ified individuals at doses determined solely by what the patient can afford. This has led to a much higher preva- lence of resistant strains in developing countries than in developed countries, where the sale of antibiotics is re- stricted and appropriate clinical ser- vices are more readily available. To ameliorate the impact of these diseases on public health, countries have adopted various strategies and approaches in their control pro- grammes which include two extremes. In some countries where prostitution is believed to be a significant factor in the transmission of these diseases, "control programmes" tend to devote their resources almost exclusively to providing some sort of screening or preventive treatment for these wo- men. Unfortunately, such programmes are often of poor technical quality , reach only a fraction of the target population, and in general have failed to produce a demonstrable impact on STD morbidity in the community. Health policy makers are frequently satisfied that, by implementing "pros- titute control," enough is being done and that additional resources need not be devoted to STD problems in the community. Elsewhere a network of STD clinics may be made available at most urban centres where patients are diagnosed and treated without charge by special- ists and where the various elements of good patient management are applied including contact tracing, health edu- cation and patient counselling. But such programmes are extremely costly and beyond the reach of most health budgets. All too often the social stig- ma attached to these diseases would make it difficult for patients to attend such clinics and have their sexual con- tacts referred for treatment. The widespread and complex prob- lem of sexually transmitted diseases needs to be addressed within the much broader framework of the existing primary health care service and its supportive structures. This underlines the need to increase the competence of health services close to the com- munity so as to deal more effectively with the STD problem. Within this context the STD pro- gramme in WHO has given priority to developing methods and technologies which enable health care units-even with minimal or no laboratory diag- nostic support- to provide effective treatment to STD cases and their con- tacts; such methods can reduce the spread of the diseases and prevent the development of their devastating com- plications. In such a "simplified STD control approach," simple area- specific instructions for patient man- agement are provided to clinicians and community health workers to guide them in dealing with STD patients and their sex partners. In order to bring about a significant reduction in disease transmission and its consequences, these clinical ac- tivities will have to be supplemented by other STD control strategies (for instance, screening for asymptomatic cases, promoting changes in health and illness behaviour and so on). And all these initiatives must receive the support of the community if they are really to ensure that people can enjoy sex without harming their health. • W oRLD HEALTH, November 1986 1 I Syphilis and gonorrhoea have company by A. 0. Osoba and B. 0. Ogunbanjo omeone once said that in the beginning, when God created Adam and Eve, He also created venereal diseases, and for that reason He admonished them not to eat the apple. But Adam did eat the apple! Sexually transmitted diseases have always plagued humanity, but have never before attracted such worldwide attention as they have in recent years. Among the reasons for this are the phenomenal increase in the spectrum of diseases and infections now desig- nated as STDs; the alarmingly high and continuing increase in the preva- W oRLD HEALTH, November 1986 • lence of these diseases-with no re- spect for race, creed or status-in both developed and developing parts of the world; and the enormity of the prob- lems they generate with regard to management and control. More than 20 micro-organisms are now recognised as STD agents and they include viruses, bacteria, para- sites and fungi. Venereal syphilis occurs throughout the world, but increasingly so in areas where yaws used to be endemic in Africa, South-East Asia , the Western Pacific, South America and the Carib- bean. It is one of the most serious and deadly of the STDs, and most cases tend to be sporadic and concentrate in the towns. As with most STDs, the victims are usually the sexually active, especially prostitutes, soldiers, sailors, homosexuals and so on, aged between Top row: Gonococci-micro-organisms causing gonorrhoea, and the crab louse Phthirus pubis. Second row : Candida, a yeast-like fungus, causes candidosis and Herpes genitalis produces genital ulcers. Photos W HO 5 -Syphilis and gonorrhoea have company 15 and 30. Younger people are in- creasingly afflicted as a result of a general early onset of sexual experi- ence and promiscuity. The disease is usually acquired by sexual contact with infected persons , although non-venereal contact among children has been documented. Most morbidity and mortality caused by venereal syphilis, especially in adults , is due to the variable occurrence of late manifestations of illness in the skin , bones, central nervous system or viscera, particularly the heart and great vessels. In the developed world , the esti- mated incidence has dropped consid- erably , especially the late manifesta- tions , since the introduction of penicil- lin. Yet syphilis follows gonorrhoea and chickenpox as the third most fre- quently reported communicable dis- ease in the United States , with an estimated incidence of four to six cases per 10,000, while in the United King- dom the incidence is about one case per 10,000. The overall picture in developing countries , especially in tropical Africa, is unclear to say the least , to judge by the available statistical data. The gen- eral consensus , however , is that the prevalence of infectious syphilis is much higher since very high rates have been reported in many large towns of Africa. Fortunately , reliable methods of diagnosis are available and so is anti- biotic treatment. Late complications of venereal syphilis may be relatively less of a problem today than they were in the pre-antibiotic era , but they still constitute a problem in certain sectors of the population. The strategy should be to maintain vigilance in detecting, treating and preventing the early forms of the disease. Gonorrhoea is sometimes referred to as "the drip", "clap", or " the bug " . Few countries have reporting systems that permit an accurate esti- mate of the true incidence of gonor- rhoea. It is already the most frequently reported communicable disease in the United States, and persistent high inci- dence levels are reported from Euro- pean countries as well. In the develop- ing world , the situation is even more frightening ; in parts of some African 6 countries , the prevalence of gonococ- cal infections is as high as 10.6 and 18.9 per cent. These remarkably high figures have been attributed to a rise in promiscuity which may in turn have been influ- enced by the availability of contracep- tive pills for women , the mobility of populations , and the rejection of tradi- tional morality by young people. Control has been made more dif- ficult by the presence of large numbers of infected patients with no obvious symptoms. For instance , it is estimated that up to 60 per cent of women and up to ten per cent of men with gonor- rhoea have few , if any , symptoms. maladie transmise sexuellement 873-3310 codapltone Poster advising where to ring in case of VD, in Montreal, Canada . Photo WHO Another complicating factor is the recent development of antibiotic-re- sistant strains of the gonococcus . Such " super-strains " have now invaded vir- tually every part of the globe, account- ing for 40 per cent of all gonococcal strains in the Far East and between 50 and 80 per cent in Nigeria. While the immediate consequence is the need for more expensive antibiotics for effec- tive treatment, there has been an in- crease in complications . Most of the effective antibiotics are either not readily available in developing coun- tries or are too expensive and out of reach for an average patient. As a result , quacks and native healers are having a field day ! One of the serious consequences of untreated gonorrhoea in the mother is eye infection in newborn infants , and of more recent concern is the develop- ment of conjunctivitis not only in in- fants but also in adults due to the resistant gonococcus. By the time such patients receive effective treatment, they may have developed corneal per- foration and blindness. There is also a rise in the incidence of prepubertal gonococcal vulvo- vaginitis especially in tropical Africa. Direct contact with infected towels , bed-sharing with infected parents , carelessness concerning personal hygiene and sexual assault are some of the factors responsible. These factors, coupled with bizarre social customs and practices , as well as the longer survival period of the gonococcus in a tropical environment, account for this high incidence in the developing countries . Various other complications requir- ing extensive medical care may de- velop in both sexes. In males, they include urethral stricture, obstructive sterility and so-called " watering-can perineum " - with multiple perineal abscesses rupturing and discharging pus through the perineal skin. In females , pelvic inflammatory disease (PID) , tubal blockage and infertility are frequently seen , especially in the developing world. As much as 30 to 40 per cent of infertility in women, particularly in Africa, is a result of blockage of the fallopian tubes follow- ing gonococcal PID. Apart from the personal anguish resulting from these conditions, infertility-especially in tropical Africa-means terrible humili- ation and loss of social identity. Reports have been published of cer- tain African villages where children are hardly seen around because the women have been sterilised by gonorrhoea ! Prevention of this malady depends on early diagnosis and effective treat- ment of patients and contacts as well as proper health counselling. The use of condoms , diaphragms and cervical caps or of various spermicidal and bactericidal agents may have some benefit , and to a lesser extent so may the act of urinating, washing or douch- ing after sexual intercourse. The use of prophylactic antibiotics immediately before or soon after sexual intercourse is common practice in some develop- ing countries , but has obvious disad- vantages and should be discouraged. Perhaps in this unending race between humans and the gonococcus , the best W oRLD HEALTH , November 1986 hope lies in the development of an effective vaccine as prophylaxis. Other STDs. Few people would have imagined a decade or two ago the extent to which such traditional venereal diseases as syphilis and gonorrhoea have been overshadowed by a " second generation" of STDs. And these are now not only more widespread but also more difficult to diagnose and manage. Chlamydia trachomatis is one mi- cro-organism that has been associated with many disease conditions, includ- ing non-specific urethritis , now as common if not commoner than gonor- rhoea in many parts of the world. It also affects the testes, eyes and joints, and causes virtually the same compli- cations as those associated with the gonococcus. Mycoplasma and Ureaplasma urealyticum also produce urethritis, but their importance lies in the fact that they attach themselves to sper- matozoa and may inhibit conception ; in women, they have been associated with abortion or still-birth. Herpes genitalis is a disease that has rapidly become more widely recog- nised. It is probably the commonest cause of genital ulceration in de- veloped countries and is now found with increasing frequency also in de- veloping countries. It gives rise to painful superficial sores, often self- limiting but recurrent, and may also cause severe illness and even death in newborn infants. Cytomegalovirus is another virus that can be sexually transmitted and is a cause of congenital malformations. The contribution of sexual transmis- sion to the spread of this infection in tropical countries is not yet clearly known. Genital warts are also viral infec- tions, and may involve the external genitalia as well as the internal struc- tures such as the vagina, cervix and urethra. Although of low infectivity , they have the capability of becoming massive, causing destruction of the genitalia or obstruction of the birth canal in pregnant women. In African women, the virus has been associated with cancer of the cervix-the com- monest cancer among the female population in Africa. W oRLD HEALTH , November 1986 Syphilis and gonorrhoea have company Group B streptococcus gives rise to febrile sepsis in the mother and neonatal sepsis in the child. This or- ganism has gained wide recognition recently, particularly in the developed countries. "Tropical venereal diseases" com- prise lymphogranuloma venereum (LGV) , chancroid and Donovanosis (granuloma inguinale). LG V initially appears as a transient genital sore associated with the matting together and swelling of the inguinal lymph glands. In late stages, with the chronic Laboratory producing drugs to treat STDs. Photo W HOfT. Farkas involvement of lymphatic channels, it gives rise to " elephantiasis" -massive enlargement of the lower limbs re- sembling those of an elephant and destruction of the external genitalia. Chancroid is the commonest type of genital ulceration in some tropical African countries, especially in East Africa. One local community in Nigeria calls it " the cut-cut" because it damages the penis and is greatly feared. Donovanosis, a granulomatous lesion capable of extensive destruction of the genitalia in both sexes, is more commonly seen in India, South-East Asia, New Guinea, Central Africa and Central and South America. Though these three diseases are very prevalent in developing countries , very little is being done to control them. Vaginal discharge is a common and important problem with the female population . It is a world-wide problem whose causative agents may be yeasts ( candidosis), Trichomonas vaginalis (trichomoniasis) , Gardnerella vagin- alis, and anaerobic organisms (bacte- rial vaginosis). Studies across Africa indicate that 10 to 30 per cent of women are infected with Trichomonas vaginalis, a small parasite of the vagin- al cavity which is almost always sexu- ally transmitted and may cause severe discharge and discomfort to the in- fected woman. Men function as a transmitter of the parasite but rarely develop symptoms. Scabies caused by mites and pediculosis of the genital region -louse infestation-may be sexually transmit- ted. And unorthodox sexual practices have further expanded the spectrum of STDs to include diseases such as shigellosis, amoebiasis and giardiasis . Acquired Immunodeficiency Syn- drome (AIDS): this apparently new disease labelled by journalists as "Killer Sex Disease" is currently oc- cupying the front pages of most news- papers all over the world . Many cases have been documented in both de- veloped and developing societies. More than 14 African countries have now been epidemiologically linked with the disease and there is alarm that it may spread to other areas. The main feature of this disease is that it des- troys the body's natural immunity, leaving the victim highly susceptible to simple infections which are normally repulsed without harm. While the ma- jority of cases in the "Western" world are linked with homosexuals and in- travenous drug users, on the African continent heterosexual transmission is the usual mode of infection. AIDS has now become one of the most serious communicable diseases to threaten mankind , and is certainly the most serious STD. Sexually transmitted diseases pose major public health problems all over the world. Unfortunately social taboos about even discussing them, let alone controlling and preventing them, act as a powerful brake on the energetic counter-action that needs to be taken. Only by facing frankly the less palat- able facts of human nature , and by recognising the vast scale of problems that are all too often "swept under the carpet", can health care providers and consumers alike give adequate priority and provision to controlling and pre- venting these diseases. • 7 The social environment The basic social conditions which have boosted the incidence of STDs are unlikely to change. So it is all the more important for countries to create suitable education programmes to deal with them 11 he so-called "permissive socie-ty" and sweeping changes in at-titudes to sexuality in the North , and increasing migration to the cities and the breakdown of traditional cul- tural patterns in the South , have led to an increase in sexually transmitted diseases almost everywhere in the world. Not only has the incidence of diseases increased; the number of dif- ferent diseases recognised has also risen . To the old trio of syphilis, gonorrhoea and chancroid have been added a "second generation " of STDs, including chlamydia , non- gonococcal urethritis , trichomonas vaginalis, herpes, genital warts and hepatitis. Now AIDS must be added to the list. The explosion of STDs in the cities of the Third World today is a reflec- tion of what happened in Europe fol- lowing the urbanisation which accom- panied the Industrial Revolution. By the turn of the 20th century , some 60,000 people were dying of syphilis every year in Britain. A serological survey taken in London in 1914 indi- cated that 14 per cent of men and seven per cent of women were suffer- ing from syphilis-and the rates for gonorrhoea were believed to be even higher . These kinds of level of STDs can be found elsewhere in the modern world. One recent survey in Ondo State, Nigeria, indicated that one in every four or five women had been infected by a sexually transmitted dis- ease. Other studies have estimated that some populations in Africa and Asia show prevalence rates of gonor- rhoea ranging from three per cent to over 18 per cent. 8 by Maggie Jones The advent of antibiotics and the provision of free confidential services for the diagnosis and treatment of people suffering from STDs helped to overcome these diseases in Europe and North America, and in developed countries syphilis has been declining ever since. However since the Second World War , and particularly in the 1960s, changes in attitudes towards sexuality and increasing sexual ex- perimentation outside marriage have led to a further increase in gonorrhoea and other sexually transmitted dis- eases in the developed world. In the United Kingdom, for exam- ple, the reported incidence of gonor- rhoea rose from 35,500 in 1962 to a peak of 66,000 in 1973. While much of the increase may have reflected the fact that more people were seeking treatment and thus increased the level of reporting of the disease , there is no doubt that the rise in incidence of the disease is genuine and is based on changing sexual behaviour. Since 1973, cases have fallen to 53,800 in 1984, and cases of gonorrhoea now form only one-tenth of the total number of STD cases reported annu- ally in the UK. However , this decrease of gonorrhoea cases is amply balanced by a continuous increase of non- Bar-girls in a South-East Asian city. Travel- lers, beware! Photo W HO/Zafar W oRLD HEALTH, November 1986 gonococcal urethritis which is now twice as frequent as gonorrhoea. In the United States, where it is more difficult to get accurate statistics because much treatment is private and goes unreported, reported gonorrhoea rates fell from their post-war peak during the late 1940s and 1950s but · then began to rise again after 1957, reaching an all-time high in the mid- to late 1970s of around a million cases a year; (because of under-reporting, the true annual figure is estimated at two million). The true incidence of STDs in the developing world is very difficult to discover. In some countries they are not reported at all. In others only the " traditional" STDs are reported, the remainder being ignored. Under-re- porting occurs everywhere , especially in those countries where STDs are mainly treated privately, rather than as part of a public health programme. All too often facilities for diagnosis and treatment are painfully inad- equate, and people rely on traditional remedies, most of which may be com- pletely ineffective. Further, in some societies women are reluctant to come forward to seek diagnosis and treat- ment, especially if women doctors are not available. The reasons for the increasing inci- dence and number of STDs are com- plex. The increasing drift of popula- tions into the big cities in all societies , changing marital patterns (with di- vorce becoming much more common) , and the tendency for people to enter sexual relationships at an early age and to have more sexual partners during their lifetime have all had their influence. The young are the most sexually active age group, and since the Second World War the proportion of young people in most countries has risen rapidly and is continuing to rise. Ac- cording to UN estimates , the number of young people aged 15 to 24 in Africa is expected to double by the year 2000, and in the Arab countries the 15 to 24 age group represents a fifth of the total. This is in direct contrast to the aging populations of the developed world , although those countries had their post-war "baby boom" which gave rise to a large population of young people in the W oRLD HEALTH, November 1986 Many parts of the world maintain strict norms for women's dress. Photo L. Sirman © 1960s and 1970s and has a bearing on changing sexual mores among the young. Increasingly, homosexual men, who may now feel more free to express their sexuality, have been infected with and have passed on STDs; the majority of cases of syphilis in the developed world now occur among male homosexuals. Homosexual men are particularly important in spreading STDs because of their promiscuity, which may be extreme in some cases. While Kinsey in 1948 found that the average homosexual man had three sexual partners in his lifetime, more recent studies have indicated that the average number is more than 50 , and in some populations it is much higher than this. Homosexual men are also at particular risk of contracting other sexually transmitted diseases, includ- ing AIDS and such bowel infections as giardiasis. Easy access to contraceptive methods and the removal of fear of pregnancy have had a powerful effect on sexual freedom . Changes in the use of contraceptive methods may have had their impact too. Barrier methods, particularly the condom, are known to protect against STDs, whereas in- creasing use of the contraceptive pill and the intra-uterine device (IUD) instead of barrier methods may have increased the number of disease complications. Increasing urbanisation in the Third World has had a powerful effect on attitudes to sexuality and sexual behaviour . Increasing populations m 9 many farming areas have led to short- er fallow periods for the land , lower yields and smaller family plots , with the result that young men move to the cities in search of work , leaving behind the traditional villages and way of life. In a village everyone knows every- one else; it is very difficult to keep an extra-marital affair a secret; and the traditional culture had strong sanc- tions against such behaviour. But when people go to the cities they leave behind such constraints and frequently experience loneliness and disorienta- tion ; they are also bombarded by sophisticated films, literature and ad- vertising all of which tend to promote free sexual activity . In these circum- stances sexual experimentation, whether heterosexual or homosexual , is likely to be on the increase. The traditional morality is being challenged by the young throughout the Third World , especially where it seems inappropriate to the conditions in which people are now living. Mar- riage at a young age and arranged marriages become less popular in the face of imported ideas of romantic love-alas , too often tarnished by reality-and increasing freedom to mix with other young people . Women in- creasingly seek educational oppor- tunities which offer them an alterna- tive to youthful marriage and parent- hood , and these women are then more likely to enter sexual relationships outside of marriage . Young men, lack- ing in guidance or experience, may view the young women in their age group as " fair game" if they are not going to marry them , and are unlikely to take precautions either against con- ception or against the risk of sexually transmitted diseases. The huge increase in migrant labour throughout the world , opened up by easier travel and by labour shortages in some countries or meagre employ- ment prospects in others, has meant that large numbers of men are going abroad to work-an estimated four million migrant workers in Europe alone. These are usually unattached men who, until they have settled into the new cultural background and liv- The permissive society: boy meets girl in a European park. Photo WHOfT. Urban W oRLD HEALTH, November 1986 Discreet veils for the women in the Eastern Mediterranean. Photo L. Sirman © ing situation and formed stable rela- tionships, are at risk of acquiring STDs through casual sexual encounters. Men working temporarily away from home in distant cities on engineering projects are also at risk of contracting STDs and passing them on to their wives or others in their communities when they return home. The increasing ease and cheapness of air travel for tourism means that STDs can be spread from one region to another, and new kinds of infection can be brought to distant countries. Casual sexual relationships are not uncommon on foreign holidays, espe- cially in cities which notoriously make money out of sexual entertainment. Attitudes towards STDs affect people's willingness to seek treat- ment if they suspect they are infected, and so of course does the availability of suitable health services. In most African countries , only 30 to 35 per cent of people are reached by modern health services, which are situated W oRLD HEALTH , November 1986 mainly in the cities. Furthermore, peo- ple suffering from STDs do not like the reason for their visit to be iden- tified: rather than special clinics, STD diagnosis and treatment in a general health care facility may be much more appealing . Young people in particular may be afraid of going forward for treatment , in case their parents find out, and women tend to feel embarras- sed and ashamed. For some young- sters, however, there is no problem: gonorrhoea is viewed as a "man's disease ," and you're not a real man until you've caught it! Education is a key factor in helping to persuade people to seek treatment -keeping them informed of what the diseases are and the consequences of not having treatment. Unfortunately, since the advent of penicillin-resistant strains of gonorrhoea isolated in West Africa and the Philippines in 1976, and with the new generation of dis- eases, some of them viral , which are less easy to treat, some of the impetus may have gone out of seeking treat- ment. Where people feel that their condition is unlikely to respond to medical treatment , they are more likely to neglect it or use traditional herbal remedies , sometimes with devastating consequences. In most Third World countries , anti- biotics are available over the counter at pharmacies or even in general stores and market stalls. People who realise or suspect they are infected with an STD may take the wrong or incom- plete dosage, which will fail to clear up the infection and , worse, will promote the transmission of antibiotic-resistant strains. Where the diseases are understood and treatment is freely and confiden- tially given, the problem is not a major one. There are many areas throughout the world, however, where people not only know very little about STDs and how they are transmitted, but do not know where they can turn to for advice and effective treatment, or are ashamed of doing so. The underlying social conditions which have led to the rise in STDs throughout the world are unlikely to change in the short-term. So it is all the more important for countries to stop ignoring the problem but to accept that the STDs are a fact of life , and to create appropriate edu- cational and health programmes to deal with them. • 11 Acquired Immunodeficiency Syndrome (AIDS) A global challenge he Acquired Immunodeficiency Syndrome (AIDS) and the entire spectrum of disease associated with human immunodeficiency virus (HIV) infection has recently and rapidly become a problem of intense international interest and concern. HIV disease is not simply one of a series of newly emerging diseases dur- ing the past decade, but has several biological and epidemiological fea- tures which together justify a unique sense of urgency . among public health officials, physicians, political leaders and the general public. The aetiologic agent of AIDS, the HIV virus, differs in important ways from more traditional human viral pathogens such as hepatitis B , poliovirus or measles virus . HIV at- tacks elements of the immune system and the nervous system (brain) , and results in an infection most virologists believe to be lifelong. The factors influencing the viral activity level are currently unknown, but it is clear that the virus can move readily from a resting or dormant state to intense activity. This results in a breakdown of body resistance and subsequent disease manifestations of varying severity. The full range of disease expressions of HIV infection are not yet fully known. AIDS, the most severe cur- rently recognised consequence of HIV infection, is characterised by destruc- tion of key elements in the host im- mune system, resulting in a series of severe, and ultimately fatal , oppor- tunistic infections and malignancies. Available evidence predicts that at least one to two per cent of HIV 12 by Jonathan Mann infected persons will develop AIDS each year. A series of severe yet lesser clinical manifestations of HIV infections are classified as the "AIDS-related com- plex" , or ARC. Persons with ARC suffer ill health in the form of chronic fever, diarrhoea, weight loss, night sweats and swelling of lymph glands. Condoms on public sale from a machine. Their use is strongly recommended for any- one at high risk of AIDS. Photo WHO/G. Safar Current data suggest that approxi- mately five to ten per cent of HIV infected persons will develop ARC each year. ARC cases are also at increased risk of progressing to AIDS itself: again five to ten per cent per year. HIV also behaves like a "slow vi- rus" infecting the central nervous sys- tem. It appears responsible for a vari- ety of neurological syndromes, ranging from acute inflammation of the brain to chronic dementia. The relatively recent discovery of HIV virus and the short observation period of known infected persons limit the ability to predict the eventual neurological bur- den associated with HIV. Manifesta- tions of sub-acute and chronic HIV infection of the brain may only become evident during the next 10 to 30 years. Nevertheless, the possibility clearly exists that neurological damage may represent the most destructive aspect of HIV infection. Finally, other adverse consequences of HIV are likely to emerge during the next decade. Given the central role of the immune system in a wide range of disease states, especially malignancies and "auto-immune" diseases, the re- sults of HIV -associated immunologi- cal dysfunction may be far-reaching. In summary, the ultimate health im- pact of HIV infection, including ef- fects on future generations, is un- known, and the currently recognised syndromes constitute an unknown portion of the HIV problem. The infection of sexually active women creates the problem of perinatal transmission of HIV. The likelihood that an infected mother will transmit HIV to her newborn child is estimated to be 25 to 50 per cent. Therefore , in those areas of the world where eight to ten per cent of pregnant women are infected , as many as two to five per cent of all newborn children may be infected with HIV during the perinatal period. As a result, the HIV -infected per- son, even when he or she feels healthy , faces a distinctly uncertain future , with W oRLD HEALTH, November 1986 a risk of approximately ten per cent of developing AIDS , a 25 per cent risk of ARC, and an unknown risk of nervous system affections during the initial five years after infection. The annual risk for infected persons of developing AIDS or ARC may remain constant or even increase during the first five to seven years after infection, and the ultimate cumulative risk for infected persons is unknown. In population terms , therefore , the scope of the HIV problem cannot be measured in terms of current AIDS cases. As more years of observation accumulate, a clearer picture will emerge. Current estimates suggest that, in the developed and developing world, there are approxi- mately 50 to 100 (or more) HIV- infected persons for each case of frank AIDS. For example , in the United States, between 1 and 1.5 million persons are thought to be infected, and therefore susceptible to HIV- associated health problems. AIDS and ARC are costly diseases in human and financial terms. Due to its modes of transmission (predomi- nantly sexual), approximately 90 per cent of cases in developed and de- veloping countries are between 20 and 49 years of age. The particular impact on younger persons is reflected in New York City (Manhattan) and San Fran- cisco, where AIDS has become the most important cause of premature mortality (years of expected life lost) among single men 25 to 44 years old. Thus, the loss of human potential must be added to the extraordinary finan- cial burden of an incurable disease. In the United States, the average in- hospital treatment of each AIDS patient has been estimated to cost US $40,000. In developing countries , AIDS patient care depletes the al- ready limited health care resources . Finally, the lack of any recognised effective treatment for HIV-associ- ated immuno-suppression limits medi- cal care to treatment of secondary effects (infections, cancers) and allevi- ation of pain. The person-to-person transmission of HIV is dominated by the role of the apparently healthy yet infected person ("carrier"), who is clearly capable of transmitting the virus , and of whom there may be , as mentioned above , 50 to 100 or more for each recognised AIDS case. Regardless of the area of the world studied, the modes of HIV W oRLD HEALTH, November 1986 Above: Most virologists believe HIV virus infection is lifelong. Photo WHO/Pasteur Institute, Paris Below : AIDS research at a maximum safety laboratory in Australia. Photo WHOff. Farkas in most countries today, all blood donations are routinely tested for the HJV virus. Photo WHO/P. Almasy transmiSSion are fundamentally the same: (1) sexual contact with an in- fected person; (2) exposure to con- taminated blood and blood products ; and (3) from infected mother to child before, during, or shortly after birth. Two "classic" epidemiological pat- terns have been recognised in the developed and developing world. In the developed world, transmission is currently most important among male homosexuals and bisexuals and in- travenous drug users. Thanks to screening programmes and other mea- sures, blood transfusions and clotting factors used in the treatment of haemophilia have virtually ceased to be a mode for HIV transmission in 14 these areas. In parts of the developing world (such as Africa and the Carib- bean) , heterosexual transmission dominates the epidemiological scene. Persons receiving injections or other treatment with contaminated needles and other skin-piercing instruments , and infants born to infected mothers and recipients of untested blood are also at risk of infection. Throughout the world, sexual con- tact is of primary importance in HIV transmission. This mode of transmis- sion creates extraordinary problems for control efforts as sexually transmit- ted diseases have demonstrated an ability to spread rapidly and efficiently within countries as well as internation- ally. Sexuality and related issues are generally difficult to discuss openly due to complex social and religious factors . Nevertheless , in the ab- sence of a vaccine, prevention of sexual transmission tlepends upon educational strategies which will require a strong focus and a creative approach to be successful. Several areas of the world are now experiencing substantial endemic or epidemic HIV-associated disease, par- ticularly North America , Europe, South America, Africa and Australia. With the exception of North America, Europe and Australia , which together reported 29,682 AIDS cases as of 9 October 1986 (86 per cent from the United States) , the numbers of re- ported cases do not reflect the actual AIDS situation. For example, while only 15 African countries have offi- cially reported a total of 1,008 AIDS cases , the AIDS incidence in several cities of central Africa is known to equal or exceed incidence rates in New York and San Francisco. The AIDS situation in Africa illus- trates the scope and dramatic nature of the current HIV pandemic. Studies W oRLD HEALTH , November 1986 from several countries have docu- mented a two to 20 per cent rate of HIV infection among healthy adults in the general population . In one Afri- can city, one in 500 (0 .2 per cent) healthy mothers were HIV -seroposi- tive in 1970. In 1984, sera-prevalence in a sample of women aged 20 to 39 from the same city was eight per cent-a 40-fold increase compared with the early 1970s. The conse- quences of this recent dramatic in- crease in HIV infections in central African countries include a substantial number of AIDS cases , an increasing number of children infected at birth · by HIV, and complex interactions between HIV infections and endemic diseases of public health importance (such as tuberculosis). In addition to evidence that the HIV problem has been increasing in those areas (presumably affected since the mid-to-late 1970s) the geographic extent of HIV infection in Africa is increasing. For example, sero- epidemiological studies among prosti- tutes in an East African city suggest that HIV was introduced into that population in the early 1980s. The high percentage of these prostitutes infected by 1985 , combined with the now measurable sera-prevalence among healthy mothers in the same area and the virtual absence of recog- nised AIDS cases in that country until very recently (1985) , illustrates that viral penetration into the community will be substantial by the time the first clinical "AIDS cases are recognised. The recent report that 20 out of 289 prostitutes (seven per cent) in a West African country were HIV sero-posi- tive is also of concern, although the extent of viral dissemination in West , East and Southern Africa is currently unknown. Despite difficulties in generalising about an entire continent, an esti- mated one to two million or more persons may be infected with HIV in Africa. If one million persons are assumed to be infected and the most conservative rate of annual pro- gression to clinical AIDS is assumed , (one per cent per year) , a minimum of 10,000 AIDS cases annually may be occurring in Africa. The world can be divided into three areas , according to their current HIV problem. The first group includes the W oRLD HEALTH , November 1986 Acquired Immunodeficiency Syndrome (AIDS) Ensuring the safety of blood and blood products The AIDS epidemic has resulted largely from sexual spread of HIV; transmission by blood transfusion or blood products has played a relatively minor role . Nevertheless, a great deal of public concern has been expressed about the safety of blood and blood products. Fortunately, effective con- trol measures can reduce markedly the risk of transmitting AIDS by this route. Such measures must be consi- dered in the larger context of national activities towards AIDS prevention. As a result of several meetings organized by WHO, a series of recom- mendations have been formulated, a summary of which is given here. - The public should be clearly in- formed that blood donation itself does not incur any risk whatsoever of in- fecting donors with the AIDS virus. - Donor education and selection pm- grammes are guaranteed to eliminate potentially infectious units of blood and plasma from being collected. - Donors should be made aware in advance of thei.r donation that their blood will be tested for the presence of serological markers of virus infec- tion. - Blood for transfusion and prepara- tion or components should be tested for antibodies to H IV when the risk of transmitting the virus is significant. and when the benefits of such testing outweigh other important factors in providing blood. - Blood from which plasma deriva- tives are manufactured should be shown to be free of serological mar- kers of HIV in areas where the virus is prevalent. Specific exceptions might be considered appropriate by national control authorities based on therapeu- tic benefit and safety of the product. - Countries which import blood pro- ducts should consider, wherever feas- ible, reviewing manufacturing pro- tocols so as to assess the acceptabili- ty of the products, taking into con- sideration these conclusions and re- commendations . - WHO should provide reference materials and sera for use in evaluat- ing and standardising laboratory tests . - wHo should attempt to establish uniform scientific criteria for heat inactivation. chemical treatment and serological testing of blood products regarding AIDS. - wHo should revise its requirements to take new manufacturing and screening procedures into account. (From Weekly Epidemiological Record : No. 18, 2 May 1986) developed countries which have been dealing with AIDS during the past several years. These countries recog- nise the public health importance of HIV infections and command suffi- cient resources to address many as- pects of this problem. The second group of countries includes those that are apparently free , or nearly free , of HIV infection. These include both developed and developing countries, who currently have the enviable op- portunity to take rational steps to protect themselves against the HIV pandemic. Some of these countries have the resources needed to under- take surveillance activities , yet others do not. Finally , in the third group are the many countries in the developing world which currently face an AIDS crisis. As already mentioned, some of these countries are characterised epidemiologically by heterosexual transmission , transmission by non- sterile needles, syringes and other skin-piercing equipment, perinatal transmission and spread through un- controlled and unscreened blood transfusions. These countries must confront a complex HIV problem superimposed upon the already severe public health problems of the develop- ing world , such as malnutrition , diar- rhoea! disease , measles and malaria. The alternative to concerted public health action to control AIDS is the unchecked spread of HIV infection throughout the world , ultimately reaching all segments of the popula- tion. The particular biological and epidemiological features of this infec- tion require that the HIV pandemic be seen as a unique public health prob- lem, and not just as another of many communicable disease problems fac- ing the world today. Uninfected popu- lations must be protected , as HIV infection in itself is an adverse health outcome of profound personal and public health importance. The appa- rently healthy infected person is not only at substantial risk of severe illness at a later date , but creates a public health risk because of the ability to infect others. Public health control of HIV cannot wait for the possible de- velopment of effective antivirals and vaccines. The solution to pandemic health problems calls urgently for in- ternational cooperation and global coordination. • 15 The keys to STD control Successful control of sexually transmitted diseases depends on: prevention based on education and behavioural change; the right treatment as soon as possible; the cooperation of the patient; Prevention Abstinence is obvi- ously a foolproof method, but equally obviously it is unac- ceptable to many people. So a number of other preventive methods need to be recommended . In order to avoid catching an infection you can: - stay away from casual relation- ships and reduce the number of your partners; use barrier methods such as condoms. diaphragms and vaginal sper- micides which may provide protection and should be encouraged regardless of the need for contraception . To be effec- tive. condoms must be used consis- tently and correctly and must remain intact. Their use protects both the wearer and his partners. Although urinating and washing the genital area after intercourse have not been proven to be effective in preventing STD trans- mission. they may help you to avoid some genital infections. 16 and treatment of all sexual contacts Top : Sex education from schooldays onwards helps to curb STDs. Above : Smear test for gonorrhoea by a qualified health worker in Singapore. WHO photos by T. Urban and T. Farkas Small inset : Swedish poster advocat- ing use of the condom. Early treatment If you think you have an infection. consult the nearest clinic or your own doctor right away. The sooner an infec- tion is recognised and treated. the easier it will be for the doctor to cure you . Here are some possible signs of infection : - heavy and unusual discharge from the vagina; - discharge from the penis with stain- ing of underwear; - a sore. a blister or a rash near the vagina. penis or anus; - pain or a burning feeling when urinat- ing and a very frequent need to urinate; - and pain when having intercourse. Sometimes there are no symptoms at all. especially in women; so if you have any reason to think that you might have been infected. go for a check-up . Remember : early treatment prevents serious complications . W oRLD HEALTH, November 1986 Self-medication is not the answer. Diag- nosis and treatment are jobs for the clinic to carry out. Photo WHO/D. Henrioud Patient cooperation This is a vital part of disease control. All too often, patients stop taking their medication as soon as the symptoms disappear. Do keep to the instructions given by the doctor and do not forget any subsequent appointment so that the doctor can make sure you have been cured . Most of all do not try to treat yourself . Medication given by a "friend" could do more harm than good, as the drug given for somebody else's problem might not be what is required for you . Taking drugs without a proper diagnosis and prescription may only reduce the symptoms without get- ting rid of the disease. Above : Dispensing drugs at an East African health centre. Below : Consultation at a skin-clinic in South-East Asia. WHO photos by W. Lindwer and T. Farkas The sexually transmitted diseases contact tracing brigade in Singapore. Photo WHO!T. Farkas Treating contacts If you have been diagnosed as having an STD, you should stop having sex until treatment is completed . But any sex partners you have had over the previous months, casual or steady, should also consult the clinic or a doctor and be given the benefit of treatment since they may be infected without knowing it and may be infectious to others-including yourself! W oRLD HEALTH, November 1986 17 Prevention and detection Putting the message of STD prevention across to all schoolchildren is essential for all STD programmes. But many programmes are faulty in both concept and execution revention of disease transmis- sion and early detection of dis- ease: these are the two activities which will have the greatest effect in reducing the impact of sexually trans- mitted diseases (STDs). And in prac- tice these two activities should not be separated. Although early detection is often aimed at preventing complications of infection in the individual, it may have a greater impact on disease transmis- sion because it removes a source of infection from the community. Pre- vention of disease transmission to newborn infants may be achieved most effectively by early disease detection in the mother. Health promotion activities m schools or health centres and to the general public need to emphasise both primary prevention of infection and early detection of disease. Although it is necessary for health planners to distinguish the individual sexually transmitted diseases when they draw up early detection programmes , expe- diency demands that educators treat these diseases as a group for health promotion programmes so as to en- sure that the health message is suffi- ciently simple . Getting the message to all school- children is an essential part of STD programmes. Unfortunately many existing programmes arefaulty in both concept and execution. Using special- ised health workers or educators to teach schoolchildren is an extravagant use of scarce resources. These highly qualified personnel can be more profitably used to train teachers and primary care workers at one-day workshops and then to support these trainees m educating the general public. 18 by Gavin Hart Beside being simple, the health promotion message should be directed towards achieving specific goals. Stu- dents should understand the general symptoms which may indicate an STD (and the fact that infection is fre- quently asymptomatic), the ways in which the diseases may be transmitted, ways of preventing infection, when to seek medical care and where appropri- ate care is available. Common mis- understandings include the failure to A prostitute calls for her regular medical check-up in an Asian port. Photo W HOfT. Farkas associate patchy hair loss or general- ised skin rashes with syphilis, or lower abdominal pain with gonorrhoea or chlamydial infections. The erratic way in which sexually transmitted infec- tions are passed on during sexual ac- tivity may also cause confusion. Most infections can be transmitted by oral and rectal sex as well as by conven- tional heterosexual intercourse, but it frequently happens that some sex partners of an infected person become infected whereas others do not. Patients at health centres are impor- tant targets for health promotion, but they in turn may also provide useful information to health workers . Posters or postcards can be used to illustrate the clinical features of various dis- eases, and subsequently patients can often identify individuals within the community who may have the symp- toms or who behave in others ways which may suggest infection. For in- stance, aboriginals in many Central Australian communities often respond to the patchy hair loss caused by syphilis by wearing woollen caps. Encouraging women to seek early antenatal care is an important educa- tional priority for both schools and health centres. Testing pregnant wom- en for syphilis has almost eliminated congenital infection in most parts of the world, but sporadic cases still oc- cur in developed countries, usually in children of mothers who have had little or no antenatal care . Testing selected individuals who have recently visited the big cities can be a produc- tive activity for rural health centres. Many individuals who are at risk for STDs will be prepared to change their sexual behaviour to reduce that risk if they are given a range of realistic options. These options may include: - avoiding sex with casual acquaint- ances; - avoiding sex with individuals who have any signs of a sexually transmit- ted disease ; - avoiding group sex or anonymous sex in bath-houses or similar insti- tutions; - using a condom or other method of prophylaxis when having sex with a casual partner ; - practicing "safe sex" with casual partners . Safe sexual activities refer to W oRLD HEALTH, November 1986 those in which there is no transfer of body fluids. Complications of infection will be reduced if individuals seek medical care immediately after having unpro- tected sex with a casual acquaintance. The possibility of acquiring AIDS has caused substantial behavioural change in some groups. For instance, publicity about safe sex practices was associated with a sudden drop in anal gonorrhoea in San Francisco, USA. For the past year, many prostitutes in South Aus- tralia have insisted on all clients wear- ing a condom, regardless of the type of sex required, and this policy is often made a condition of employment by employers. Although it was triggered by the AIDS epidemic, this practice has resulted in a decrease in gonor- rhoea among both the prostitutes and their clients. On the other hand, a number of prostitutes have acquired gonorrhoea from their regular boy- friends because they do not insist on condoms for social sex. The most consistent protection When used properly, the condom offers the most consistent protection against the majority of STDs. How- ever, there is often a reluctance to use condoms among those at high risk of STDs because of impairment of plea- sure, interference with sex or un- availability when the opportunity for sex arose. A concerted campaign to improve the image of the condom and create a more open and frank sexual environ- ment greatly increased the use of con- doms in Sweden in the 1960s and there was an associated decrease in cases of gonorrhoea. Between 1964 and 1973, sales of condoms in Japan increased four-fold in response to sales strategies that included a variety of new designs, production of ultra- thin condoms to minimise any loss of sensation, and the introduction of vending machines which made con- doms readily available at any time in meeting places where casual sex might occur. Door-to-door sales had no ef- fect on the number sold, presumably Medieval monks receive instruction about the ways of a man with a maid. Illustration from a book about the classical Greek physician Galen. W oRLD HEALTH, November 1986 because of saturation of sales by other innovative methods. Urination or washing the genitals immediately after intercourse provide very little protection from STDs. Studies among Australian troops in Vietnam and United States naval per- sonnel in Asia showed that these mea- sures failed to prevent gonorrhoea. A wide range of chemicals applied to the genitals before or after inter- course have been used for protection. Most of them have some protective effect, but often require painstaking application to obtain significant ben- efit. They are often very irritating and may produce serious side-effects. Thus a group of prostitutes from Nevada brothels discontinued one trial of a chemical prophylactic because of the degree of vaginal drying and irri- tation it produced. Despite extensive research, no vac- cines have yet been produced for the STDs. The sole success has occurred with hepatitis B, but the resultant vac- cine is too expensive for routine use in developing countries where the need is greatest. Although essential for the treatment of most STDs, even small doses of antibiotic used without medical super- vision can be hazardous for both the individual and the community. A typi- cal problem was observed in South Australian clinics among men who had had intercourse in South-East Asia and had taken some oral antibiotic as prophylaxis. Between one and three months later, they turned up at the clinics complaining of severe pain or abscesses in the genital region. The small dose of antibiotic had been suffi- cient to prevent any obvious early symptoms but was inadequate to eliminate the long-term complications of infection. The widespread use of low doses of penicillin to eliminate syphilis from South-East Asia in the 1950s (which was largely achieved) probably contributed to the marked resistance of gonorrhoea to penicillin in the 1960s. As regards preventing STD in ·new- born babies, the use of chemical eye- drops (one per cent silver nitrate) is highly effective in preventing such babies from contracting eye infections from gonorrhoea. This treatment has some benefit against chlamydial infec- tion, but certain other infections can- not be prevented after birth. On the whole, screening pregnant women for STDs and treating them before deliv- ery will tend to offer more effective prophylaxis for the infant. • Can we really control STDs? Only a comprehensive approach coordinated by the health sector, at-risk groups and society at large can ensure that this is answered by a cautious "perhaps" instead of a pessimistic "no" by Fernando Zacarias he problems associated with STD are real and affect people all over the world-perhaps one out of every 20 teenagers and young adults each year. Mabel, a 26-year-old Nigerian housewife, feels that she is "no longer a women" after trying unsuccessfully for three years to get pregnant. Lewis, a West Indian labourer, spent his last dollar buying some "antibiotic pills" from a friend. Three days later he still "burns when passing water" and has developed a painful sore in his genitals . Anita, a 15-year-old student in a large Asian city, has a vaginal discharge and lower back pain but is too embarrassed to tell her mother or boyfriend . Can modern medicine and current tech- nology solve these problems? The answer is-unfortunately-no. The sexually transmitted diseases are an ancient and relentless health problem of global proportions. Syphilis, the great scourge and the "large pox" of the 17th and 18th centuries, has diminished in its sever- ity, but continues to affect pregnant women and to kill more than four per cent of all babies in some countries in Africa. Gonorrhoea, once thought to have been vanquished by the wide- spread use of penicillin, has again emerged as a major acute genital in- fection and a cause of complications in men, women and small babies. Chlamydia trachomatis, a microbe which also produces trachoma, an eye infection, and lymphogranuloma ven- ereum (LGV), a well-known venereal disease, is probably the most common sexually transmitted agent. Chlamydia is now recognised as a major-and often silent-cause of pelvic inflam- matory disease (swelling and scarring of the fallopian tubes in women) and 20 of its serious consequences, such as ectopic pregnancy, and infertility. The association between genital warts and cancer of the cervix is be- coming a source of preoccupation for health authorities in some countries. Viral infections such as genital herpes and venereal warts, against which there is no curative drug treatment, are increasing in numbers . Probably no other health problem in recent Sex education poster in a Philippines skin clinic. Photo WHO/Zafar history has received more mass media and public attention than AIDS, the acquired immunodeficiency syn- drome, a serious and life-threatening viral infection transmitted mainly by sexual intercourse . At present more than 20 different sexually transmitted viruses, bacteria, protozoa, fungi, and ectoparasites have been recognised that can cause a wide array of disease and clinical manifestations. To make matters worse, simultaneous infections by two or more microbes can occur and, with the exception of hepatitis B, no vac- cine is available to protect from these infections. The increasing incidence of STD all over the world, and in developing countries in particular, is due to sev- eral factors, including the demo- graphic explosion and the dramatic socio-economic and technological changes (such as the migration of young people to the cities, access to contraceptive methods and so forth) that have occurred in the last 25 years. Furthermore, the large numbers of young people who will reach the ages of greatest sexual activity (15 to 39 years of age) by the year 2000 will guarantee that an already serious situ- ation will get worse. However, we are not starting from zero in the global control of STD. Valuable lessons have been learned from the campaigns against syphilis after World War 11, when it became evident that the prompt and adequate treatment of patients or infected per- sons and their sexual partners would have two main effects: interrupting the chain of transmission within the community, and stopping the pro- gression of disease in the infected person, thus preventing the develop- ment of serious late complications. By detecting the presence of disease, and treating the patient and his or her contacts, it was possible to have a significant impact on the syphilis situ- ation. The technology (laboratory tests) and the antibiotic (penicillin) continue to be widely and successfully used to control syphilis in many coun- tries. However, the field of STDs has now expanded to include microbes and diseases against which we do not have simple and inexpensive labora- tory diagnostic methods or effective treatment. In other words, from a WoRLD HEALTH, November 1986 technological standpoint we are cur- rently unable to control all STDs, even in rich industrialised nations. The situation is serious but not hopeless. First, we must realise that STDs are not only a medical problem but also a problem which concerns society as a whole. Second, we must acknowledge that specific public health resources to control STDs will always be insufficient and that medical technology alone is clearly unable to deal with this problem. Finally, we must recognise that, even with a few resources, patients and infected per- sons can receive proper attention pro- vided communities and public health personnel learn to work together. Health authorities have often been so preoccupiea in providing the best possible technical care, that they have overlooked the human dimension of the STD problem. Most patients are not worried about the scientific name for their infection or the limitations of a diagnostic test. What they want is to alleviate their problem at a reasonable cost in time and/or money, and prefer- ably in confidentiality. WHO is now advocating the use of "simplified approaches to STD con- trol at the primary health care level". These approaches take into account the limitations or total absence of modern medical technology and the impossibility of having fully trained STD specialists seeing patients at gen- eral clinics or in rural health posts. But most important , they consider that the patient's problem is also a community and a public health problem. Conse- quently, both the patient and the com- munity must become part of the solu- tion. This three-pronged approach (health worker, patient, and commu- nity) can be summarised as follows: W oRLD HEALTH , November 1986 Solving the social problem of STDs calls for active collaboration on the part of health worker, patient and community alike. Photo WHO!T. Farkas Health worker. The health worker, whether physician, nurse or other health pactitioner, must know the main signs and symptoms of STD and when to suspect the presence of STD in an individual; how to ask the proper questions and examine the patient ; when to order or perform tests; how to interpret those laboratory tests available for the patient's care; and what is the most likely or most impor- tant microbe causing the patient's problem. The health worker must also develop the appropriate skills to sec- ure the patient's compliance with the treatment, including the need to re- turn if not improved, and most impor- tantly, to ensure his or her cooperation in the management of sexual partners . To guide health workers in this pro- cess, WHO encourages the design, implementation and evaluation of STD patient management protocols appropriate to local circumstances . Patient. The opportunity to educate an individual who is obviously moti- vated by the presence of a health problem should not be missed. In addition to the messages related to the patient's own treatment and the man- agement of his or her sexual partners , clear messages on how to avoid further transmission to others and to prevent recurrences or future infections should be given. Ideally, the patient should become a disseminator of health mes- sages and not of disease. Community. STDs differ from other health problems in that they occur after sexual intercourse with an in- fected person. The events surrounding transmission of disease (such as sex with prostitutes, homosexual relations, pre-marital or extra-marital sex) occur frequently but are considered "impro- per behaviour" in most societies. So the health problem is aggravated by an implicit (or explicit) moral judgement on the behaviour of the affected per- son and sexual partner. Attempts to legislate or control human sexual be- haviour have failed in the past and are unlikely to succeed in the future . Nor is it possible to change community attitudes towards "blaming the vic- tim". However, individuals and com- munities should be able to understand and accept the fact that STDs are a consequence of unsafe sex and not of sex in itself; that STDs and their complications also arise because people who are or may be infected do not know where to turn for help; and finally, that STDs may be a problem because there is no adequate help in the community (that is, nobody knows how to treat or recognise STD, or drugs are not available). A global prescription for all com- munities is not possible, but obviously community understanding, interest and commitment are necessary. Initia- tives to enlist the community's partici- pation may come from the health sector, or from individuals or private groups. It may be possible to improve existing health facilities, to enlist com- munity support to ensure that drug supplies are available , to train health personnel, to educate risk groups, or to provide general information to the mass media and the public. Access to the at-risk population, cooperation of infected persons with health authorities, provision of ap- propriate patient and sexual partner management , education and discus- sion of STDs by peer instructors, and dissemination of acceptable and effec- tive messages, can all result from in- volving those who know or should know the problem (the health sector), those who are suffering the problem (the at-risk group), and those who will pay for the problem (communities and society in general) . To return to the initial question "can we really control STD?" -only this comprehensive approach and the coordinated efforts of these three ele- ments will result in changing the an- swer from a pessimistic "no " to a cautious "perhaps" and , eventually , to a hopeful "yes". • 21 Puning babies at risk Gonorrhoea, syphilis and AIDS are three of the STDs that can be passed from the infected mother to the infant before, during and after birth unless she takes certain precautions by Andre Meheus 11 he environment of the womb has so evolved that the foetus is cocooned and protected against almost all infections. Unfortunately a comparatively small number of infec- tions can be transmitted by the mother to the unborn baby . These include certain sexually transmitted diseases , among them gonorrhoea , syphilis and AIDS. Gonococcal ophthalmia neonatorum is the medical term for a condition affecting the eyes of the newborn babies , who become infected from the mother's uterine cervix when the baby is passing through the birth canal. Between two and seven days after birth the baby develops sticky eyes. If the infection is gonococcal, in the absence of early and adequate treat- ment, the lesions progress rapidly from an infection localised on the conjunctiva-the delicate membrane that lines the eyes and eyelids-until they perforate the cornea and to- tally involve the eye . This results in blindness. At the turn of the last century , no effective control measures for this condition existed . At that time , 20 to 75 per cent of children in institutions for the blind in Europe were there as a result of gonococcal ophthalmia neonatorum. Karl Crede , a German obstetrician, showed in 1881 that plac- ing silver nitrate drops in the baby's eyes at birth prevented eye infection. This practice became compulsory by law in many countries and the infec- tion ceased to be a public health problem. Since the 1950s, with the 22 general availability of penicillin, the condition can now also be effectively treated. For health policy makers, the medical profession and the public at large, gonococcal ophthalmia neo- natorum has become a condition of no concern. However, the situation has changed rapidly in recent years , to the point where WHO is again emphasising con- trol measures against the disease. Why is this so? Firstly, in many countries eye care at birth has been discon- tinued, was incompletely applied or was not available to large parts of the community. Secondly, 1976 saw the arrival on the scene of the so-called PPNG strains of gonococci (penicillin- ase producing Neisseria gonorrhoeae ) , which are totally resistant to penicillin and its homologues. These strains spread rapidly, and in Africa and South-East Asia they are now respon- sible for 20 to 80 per cent of gonococ- cal infections. If a newborn baby de- velops gonococcal ophthalmia due to such a PPNG strain, penicillin treat- ment is of no help. The newer and more expensive antibiotics have to be used , but these are often not available, particularly in country areas of the developing world. Studies in Africa have shown that between three and 18 per cent of pre- gnant women have a gonococcal infec- tion of the cervix. The transmission rate of the infection from the cervix to the baby's eyes is approximately 30 per cent , which means that between one and six per cent of all new-born children in Africa could acquire this infection and are potentially at risk of blindness, if adequate measures are not taken. One very effective measure is to carefully wash the eyes immediately after birth with clean water, and then to apply an antibiotic (one per cent tetracycline eye ointment) or an anti- septic (one per cent silver nitrate eye drops) to the conjunctiva. If this method is applied to all babies , the condition will occur only sporadically. Furthermore all mothers should be informed that if they notice sticky eyes, they should bring the baby urgently to the health worker. All health workers should be trained to suspect gonococcal ophthalmia neonatorum, and they must consider it as a medical emergency in order to manage it adequately. And the mother should of course also receive standard treatment for gonorrhoea. Congenital syphilis is a less frequent disease than gonorrhoea , but it is an important infection because of its seri- ous consequences for the health of mothers and for the outcome of pregnancy. If a woman has untreated · syphilis, she is infectious to her unborn child. Syphilis could be suspected in the mother if she has a persistent skin rash or genital ulceration, or if it is known that her partner has the disease. But it is typical for syphilis to pass through a latent stage, when the person has no symptoms at all but the organism is still present in the blood. If this is the case in a pregnant woman, the tre- poneme- the causative organism of syphilis-can cross the placenta and infect the unborn foetus. The effect on the foetus can be a late miscarriage (from the second trimester onwards) , a still-birth , an infant death or a living child with some symptoms of congenital syphilis. The risk of these adverse effects occurring in the case of an untreated syphilitic mother is approximately 65 per cent, and her chances of deliv- ering a healthy child are only around 35 per cent. The more recent the in- fection is in the mother , the higher is the risk of an abortion, still-birth or a baby with congenital syphilis. The frequency of syphilis in preg- nancy is very variable around the world. It has become a rare condition W oRLD HEALTH , November 1986 in industrialised countries where fewer than one per cent of women attend- ing antenatal clinics are infected. But in some African countries figures between four and 20 per cent have been documented . What can be done about it? The most efficient strategy is, of course , to prevent mothers from contracting syphilis, through general control mea- sures for sexually transmitted diseases, which are discussed elsewhere. But there is a specific way of preventing congenital syphilis. All mothers should have a blood test done (it is called a serological test for syphilis) , as early in the pregnancy as possible. Ideally the test should be repeated near the end of pregnancy. If this test proves positive , it indicates that the mother has syphilis and she must be treated. Treatment is highly efficacious and consists of one to three intramuscular injections of a high dose of a long- acting penicillin. AIDS is a very recent and alarming development. Several million people worldwide have already been infected with the human immunodeficiency virus (HIV) , the causative agent of the acquired immunodeficiency syndrome (AIDS). The highest infection rates are found in North America , Europe and Africa. Risk factors associated with over 80 per cent of AIDS cases in the industrialised world are male homo- sexuality and intravenous drug abuse. The epidemiology of the infection is different in Central Africa , where transmission of the virus is mainly through heterosexual contact. This has resulted in a large proportion of women of child-bearing age already being infected with HIV in those areas ; in a number of studies the prevalence of sero-positive pregnant women varied between two and eight per cent. The mother can transmit the infec- tion to the baby in the womb , or at birth through exposure to infected maternal blood , or after birth through breastfeeding. The risk of transmission from the infected mother to the baby is not exactly known, but is probably at least 25 per cent. This means that one to two per cent of newborn babies are already being infected with HIV. The proportion of these who will sub- W oRLD HEALTH, November 1986 Marc Chagall portrayed the protected life in the womb of a mother-to-be. Painting in the Stedelijk Museum, Amsterdam, Netherlands . sequently develop AIDS and the im- pact that infection with the virus has on the general health of these children are still being closely studied . The most important counter-mea- sure is to prevent women of childbear- ing age from becoming infected with the virus. Through health education, the public should be informed of the · risks entailed in being sexually promis- cuous. Young men and women should be advised and encouraged to have stable marital and sexual relations, particularly if a pregnancy is planned or is in progress. Casual sex encoun- ters must be avoided , or intercourse must take place with a preservative (a sheath for males) . If a woman is seropositive for HIV, she should not become pregnant and should be counselled about contracep- tion. If an infected woman becomes pregnant-and a therapeutic abortion is not available to her-not much can actually be done for her and her baby. This makes prevention of HIV infec- tion of the utmost importance in all societies today. • 23 Drug resistance As the agents that cause STD became more resistant to chemotherapy, newer and more effective antimicrobial drugs were developed. Today-fortunately-effective treatment 1s available for most of these diseases W hen penicillin was first disco-vered, the two main causes of venereal diseases-gonor- rhoea and syphilis-were among the most vulnerable of all microbial agents to the new drug. However, as time went by, gonorrhoea became more difficult to treat as successfully as we would have wished. Since then, there have been several revolutions in the treatment of sexually transmitted diseases . Drug resistance usually arises when the microbe develops the ability to survive the action of antibiotics. This phenomenon may be aided by cer- tain human host and environmental factors. The mechanisms by which microbes develop resistance to anti- biotics include : - the production of enzymes that des- troy the antibiotics; - a change in the permeability of the pathogen so that drugs cannot pene- trate into the microbe; - an alteration of the microbial sur- face so that the area usually recog- nised and attacked by the antibiotic is modified; - a change in microbial metabolism. There are several factors which facilitate the development of resist- ance. Among these , the misuse of antibiotics appears to be a prominent issue. Because of the stigma attached to STDs, many patients tend to con- ceal their disease. This results in all sorts of substandard practices as re- gards the procurement and use of antibiotics. 24 by Herbert Nsanze In many developing countries the sale of drugs, including antibiotics, is very poorly controlled, and it is quite easy to obtain them without a doctor's prescription. Some drugs may even be bought from street vendors. This prac- tice has made it easy for STD patients, who are reluctant to go to clinics with Sir Alexander Fleming explains his discovery of penicillin to staff at the Haffkine Institute, Bombay. Photo WHO their problem, to obtain whatever drug they think is needed . Medicaments that are dubiously ob- tained from private pharmacies are usually inappropriately used. The wrong disease may be diagnosed or the wrong drug prescribed. The phar- macist who sells the drug has not examined the patient and therefore cannot make an accurate diagnosis. He will sell any drug requested or any of his own choice, depending on the customer's ability to pay. Frequently, even if the drug is appropriate for the disease, the customer cannot afford to purchase a sufficient quantity to effect a cure. STD patients may buy antibiotics from street vendors who claim to sell them cheaper than pharmacies do ; occasionally, some dishonest dealers will sell capsules filled with starch or other ineffective substances rather than antibiotics. When an illicitly acquired drug is self-administered, there is a tendency for under dosage ; and when the symp- toms subside, the patient will stop taking the drug altogether before a complete cure is effected. The expo- sure of microbes to sub-optimal doses for an insufficient duration is a sure way to breed antibiotic resistance. Some STD patients will consult traditional healers. All sorts of herbal remedies are given but none can be proved to have a real benefit; often the infection will continue unabated under treatment . Gonorrhoea During the 1940s, sulphonamides were fairly successful in treating gonorrhoea but their use was discon- tinued with the discovery of the won- der drug , penicillin. Initially, gonor- rhoea proved to be dramatically sensi- tive to penicillin, and this lasted for nearly two decades. Subsequently re- sistance began to develop , and in the last 30 years it has built up to such proportions that it threatens and ex- W oRLD HEALTH, November 1986 eludes its use . Other antibiotics were developed and these seemed to be very effective but , alas, again the same problem of resistance occurred. The resistance of gonorrhoea to antibiotics has thus become one of the major STD issues over the past 25 years. The appearance ten years ago of gonococcal strains that produce an enzyme capable of destroying penicil- lin, such as penicillinase-producing neisseria gonorrhoeae strains (PPNG), has compounded the problem and has made penicillin obsolete . This type of gonococcus appeared simultaneously in South-East Asia and West Africa and has now spread all over the world . Today the gonorrhoea germs are classified as either PPNG or non- PPNG. The proportion of PPNG in developing countries is extremely high. In Eastern and West Africa the PPNG rate is over 60 per cent while on the opposite side of the globe, in South-East Asia and some Pacific is- lands, it is about 30 per cent. On the other hand, in the industrialised coun- tries the PPNG rate is low as a result of active surveillance procedures. Close to 100 per cent of all PPNG strains are resistant to penicillin and to some cephalosporins, since their en- zyme destroys the drugs. They also tend to be resistant to some other unrelated antibiotics , in particular to the tetracyclines. However , there are many effective drugs for the treatment of gonorrhoea but no single drug has a 100 per cent cure rate. All ' types of gonorrhoea are highly sensitive to spectinomycin, the newer cephalospo- rins and the new quinolones. Non-gonococcal urethritis and vaginitis The two main causes of non- gonococcal urethritis (NGU) are Chlamydia trachomatis and Ureaplas- ma urealyticum. These agents and the diseases they cause are fairly sensitive to tetracyclines , erythromycin and rifampicin, with cure rates of 85 to 95 per cent. Although occasional re- sistance of chlamydia has been demonstrated, most cases of treatment failure are due to poor treatment ap- plication ; dosage and duration of treatment with these drugs vary con- siderably , even in specialised clinics . W oRLD HEALTH, November 1986 Apart from gonorrhoea and chlamydial infections in women, trichomoniasis and candidiasis are very common causes of vaginitis and vaginal discharge. Trichomoniasis is traditionally amenable to large single or multiple doses of metronidazole (flagyl), but some strains have shown resistance to it and clinical failures have been recorded. Two new related compounds, tinidazole and secnid- azole, have been shown to be effective where metronidazole fails . Vaginal candidiasis is commonly treated with nystatin or clotrimazole (canes ten) pessaries . Resistance to these drugs and infection persistence can occur but reinfections from the gut are more likely to be the culprit than resistance. Syphilis and other genital ulcer diseases Although the degree of sensitivity cannot be easily measured, the causa- Laboratory testing of new antibiotic drugs aimed at overcoming drug-resistance. Photo W HO!T. Farkas tive organism of syphilis and the dis- ease in all its stages have remained highly sensitive to penicillin. However, failures of therapy occur mainly due to the administration of the wrong types of penicillin, inadequate frequency of application or non-compliance by the patient. Persistence of syphilis organ- isms has been reported in the aqueous humour of the eye and the cerebro- spinal fluid without demonstrable effect on the progress of the disease. When penicillin is contra-indicated, the alternative drugs offered for syphilis are not as effective. Chancroid, donovanosis and herpes Chancroid (soft chancre) is a very common genital ulcer disease in the tropics of Africa, South-East Asia and South America. The drugs that were traditionally effective in chancroid therapy were the tetracyclines and sulphonamides. High resistance to these has been recently documented in laboratory testing and there have been high treatment failure rates. There are however many effective single and multiple drug regimens available for chancroid therapy. Donovanosis (granuloma inguinale) is another genital ulcer disease that is poorly understood since the causative agent has not been grown in the laboratory. It is difficult to treat be- cause the antibiotic sensitivity pattern cannot be established and the infective organism hides inside the cells (in- tracellular parasite). Additionally, it causes very extensive ulcers that take a long time to heal even when the infec- tive organism has been eradicated by antibiotics. Better knowledge of the biology of the agent is needed in order to establish its proper management. Herpes genitalis is the commonest form of genital ulcer disease in the developed countries of Europe and North America. It is proportionally less of a problem in the developing countries by comparison with syphilis and chancroid. As a virus disease , it cannot be treated with classic antibio- tics. Acyclovir has recently emerged as a useful therapy, but not a cure, for this disease ; but no sooner had its discovery been put into practice than reports of resistant viral strains began to appear. Drug resistance is not peculiar to sexually transmitted diseases; it is a problem shared by other infectious diseases. As the STD agents became more resistant to chemotherapy, newer and more effective- but often costlier-antimicrobial drugs were de- veloped. Today, despite the develop- ment of drug resistance-and always with the exception of AIDS-effective treatment fortunately exists for most sexually transmitted diseases. • 25 Endemic treponematoses One injection of penicillin, costing less than 50 US cents, could cure the endemic treponematoses in a few days, and thus save millions of children from suffering and disfigurement 11 he generic term "human tre-ponematoses" embraces four diseases which share very closely related pathogenic agents-the tre- ponemes- but whose clinical expres- sion and methods of transmission dif- fer widely. These are venereal syphilis, yaws, endemic syphilis (or bejel) and pinta. Today there are more than two and a half million cases of these diseases, 75 per cent of them children, and more than 100 million children risk becoming infected. The consequences of an infection are serious and can lead to permanent disfigurement. The dis- eases occur essentially in the poorest countries of tropical Africa, Asia, Central America, the Middle East and the Pacific, where malnutrition, respiratory conditions, diarrhoea, malaria, schistosomiasis and other parasitic diseases help to increase the sickness and mortality rates. Known since the dawn of mankind and clinically identified for four cen- turies past, their pathogenic agents, the treponemes, were described over a century ago. So they are thoroughly familiar to us, and we even have a fully effective remedy, penicillin, which can cure the infection in one single injection. Venereal syphilis is the only one of the four diseases which is transmitted by sexual contact, and is therefore virtually restricted to adults. As al- 26 by Georges Causse ways, prevention is better than cure, and probably the most promising approach to prevention is sound sex education, preferably beginning during school days. Yaws, bejel and pinta, the signs of which are principally granulating and weeping cutaneous lesions containing large quantities of treponemes, are A health worker explains the symptoms and treatment of STD in a Nigerian village. Photo WHO/P. Almasy highly contagious through simple di- rect contact , especially between chil- dren during their play, living together or using the same utensils for eating and drinking. They are often known as endemic treponematoses of childhood. The slightest injury to the skin or mucous membranes, especially the lips, can provide an entry for tre- ponemes, while flies can sometimes carry them. Young children may even transmit the disease to their parents, if they are not already immune to the condition. Poor personal and collective hy- giene linked to the scarcity of water and soap which goes hand-in-hand with poverty, an unfavourable climate, overcrowded houses, and malnutrition (which reduces resistance to infec- tions) are essential factors explaining the prevalence of these diseases. In fact they are rarely observed in towns. Yaws, also known as framboesia, buba and pian, is prevalent in the hot and humid tropical regions of Africa, Central America, Asia and the Pacific. It is caused by Treponema pertenue and is found mainly in children between the ages of two and 15 . The initial lesions on the exposed part of the body may disappear after three to six months, but others come in crops; these are secondary skin lesions, which are varied in appearance and may appear on any part of the body. The secondary and late stages may painful- ly affect the bones or cartilages and lead to deformation of the legs or may attack the face, especially the nose, causing permanent disfigurement. Endemic syphilis, also known in Arabic as bejel, is brought about by Treponema pallidum, closely related to the agent of venereal syphilis. Like WoRLD HEALTH, November 1986 yaws, it is a children's disease and produces lesions of the skin, bones and cartilages and also of the mucous membranes of the mouth. The lesions are drier than those of yaws but endemic syphilis has the same disabl- ing or disfiguring consequences. Bejel now principally affects the semi- nomadic peoples of the Arabian peninsula and the southern edge of the Sahara (the Sahel). Pinta, also known as mal de pinto (Mexico), carate (Colombia and Ven- ezuela) and azul (Chile and Peru) , is caused by Treponema carateum. It occurs only in tropical regions of the Americas , where it is particularly pre- valent in remote rural settlements and , unlike the other endemic trepone- matoses, it affects both children and adults of all ages. Red areas on the skin spread and sometimes merge. The lesions become pigmented with age, changing slowly from copper to grey to slate-blue, while some victims may develop a variegated skin-colouring. The discovery of penicillin in the 1940s with its powerful effectiveness against these diseases through a single intramuscular injection, raised great hopes of eradicating them. WHO and UNICEF launched a world-wide pro- gramme against yaws in 1948, extend- ing this later to the other trepone- matoses , bejel and pinta. Mobile teams travelling through the countries by bicycle or canoe , on W oRLD HEALTH, November 1986 camel-back or on foot to reach even the most remote villages sought to reduce the diseases to a level where they no longer posed a serious public health problem. The results were remarkable and the estimated number of cases fell from over 50 million in 1950 to fewer than two million at the end of the 1960s. Clinical cases even disappeared completely in some coun- tries. It was thought that social and economic improvements, especially in collective and individual hygiene , would overcome these poverty-linked endemic diseases. But such optimism is no longer possible today. There have not been the expected social, economic and health improvements, many of the treatment teams have been disbanded or seconded to other work, and the rural health centres, too few in number and seriously lacking staff and medicines, have been unable to cope . While endemic treponematoses have disappeared or are confined to iso- lated areas in a few countries of Cen- tral America , North Africa and the Pacific, the same is not true every- where. Yaws and bejel have spread, often in epidemic form, reaching and occasionally surpassing the levels of the 1950s, starting from old and insuf- ficiently monitored centres of disease or areas where treatment did not cover all the population . In the Sahel alone , a third or even half of the children are Endemic treponematoses Yaws, also known as framboesia, buba and pian, is prevalent in the hot and humid tropical regions of Africa, Central America, Asia and the Pacific. Here, a little girl in Laos receives treatment for non-venereal yaws. Photo WHO exposed to these infections, while between two and ten per cent of them show serious lesions. Aware that fresh and vigorous action was essential , the inter- national community, through WHO, has appealed to the national and inter- national bodies, since 1978, to mobil- ise their resources and collaborate in an attempt at the final elimination of this plague. Today, in the context of campaigns aimed at Health for all, new ap- proaches are matched to each local health situation. It is recognised that activities in the fight against tre- ponematoses must be integrated into other health and development pro- grammes provided for the same com- munities: vaccination, control of respiratory or digestive conditions, health education, improving collective and individual hygiene, nutrition and so forth. Many national, international , public and private organizations are mobilis- ing in a generous and effective cam- paign. We already have the right weapons to deal with the suffering, permanent disfigurement and disable- ment every year of these millions of children. One injection of penicillin, costing less than 50 US cents , provides a cure in a few days. And tomorrow we may discover an effective vaccine which will prevent the occurrence of these diseases. • 27 Stable lamilies-healthv children lt is rather typical nowadays that teenagers form ill-considered partnerships merely based on sexual contacts, which only result in unwanted pregnancy l]hroughout recorded human his-tory, there has always been con-flict with the " bright young things" of the day. Each upcoming new generation tends to be intolerant of earlier ones, and engages in a kind of behaviour which the older gener- ations do not know how to under- stand, or do not want to understand. The conflict is all the greater when the shifts in lifestyle are more pro- nounced. But there is little point in blaming young people for behaving as they do unless we are prepared at the same time to offer appropriate support to those in need. Statistics relating to the problems of youth show Hungary and its Central European neighbours to have a fairly average share of such problems. The country's demographical situation is also like that of its neighbours; its total population shows a declining trend, with the respective age groups changing. Fom 1970 to 1985 , the total of people aged over 50 increased by 372,000, while the number of persons aged under 25 fell by 226,000. Again as in other countries, a faster rate of physical development is a phenomenon that can best be mea- 28 by Pal Veres sured by the manifestation of the first menses of women at an earlier age than before. A century ago , the age at which women had their first menses was considered to vary from 15 to 19 years in Hungary and the neigh- bouring states. This symptom of pu- berty seems to be occurring about four months earlier every ten years in this part of Europe. In Hungary in 1984, the average age at which young girls had their first menses was around 12.5 years. VD on the rise Physical maturation at a younger age, however , does not in itself ac- count for the rise in the number of venereal diseases among teenagers. In 1984 one out of 1,150 people on average had a venereal disease , and on a global scale this is not a high ratio. But if one thinks of the consequences, it no longer appears negligible. Some 30 years ago , six per cent of males and 12 per cent of females afflicted with venereal diseases were in their teens . Fifteen years later the corresponding figures in these saddening statistics had risen to 15 per cent among men and 30 per cent among women. The situation has not improved since then. Superficially, people afflicted with sexually transmitted diseases, includ- ing the most frequent gonorrhoea! infections, can be completely cured and no longer at risk of infecting others. But the treatment may be insufficient to stop the pathological process leading to a pelvic inflamma- tory disease, in short PID. This painful disease , which in 30 to 40 per cent of the cases can lead to female sterility and all the grief that goes with it, is also a frequent cause of ectopic preg- nancy. Researchers at the Szeged Gy- naecological Clinic, who have carried out surveys supported by WHO, con- cluded, in part, that teenage abortion way lead, in one out of eight cases, to PID and, ultimately, may result m sterility. Organised research in Hungary, as elsewhere in the world , under the guidance of the International Feder- ation of Gynaecology and Obstetrics and the International Fertility Re- search Programme, and again at the initiative of WHO, is trying to define the relationship between the age of the mother , the number of births and W oRLD HEALTH. November 1986 perinatal mortality. Research workers at the Gynaecological Clinic of the University of Debrecen have proved that the second or third children born to women aged between 20 and 34 are least exposed to fetal risks, and the situation is almost as favourable as far as first-born babies are concerned. But it follows that having babies at a younger age, particularly during the teens , is a health hazard. Studies aimed at determining the optimal point of time and the most appropriate conditions for family planning are also supported by WHO. A group of research workers headed by Dr Endre Czeizel have helped 3,000 young women during pregnancy with appropriate examinations , pro- viding them with embryo-protecting vitamins and ensuring the best poss- ible cirumstances commensurate with the resources. The first such " pro- grammed" healthy and good-looking child has already been featured as a television "star" ! Another factor to be considered is that it calls for conscious education by both parents to ensure the proper physical and spiritual growth of their descendants. Families with only one W oRLD HEALTH, November 1986 parent tend to raise children who are disadvantaged in the long run. It is also rather typical nowadays that teenagers form ill-considered partner- ships merely based on sexual contacts. If such a relationship results in unwanted pregnancy-and this is not interrupted by abortion within three months, when it does not endanger the would-be mother's life-then it is often followed by a marriage contracted out of necessity owing to prevailing social prejudices. In 1984, 1,776 Hungarian women aged under 17 gave birth to a child out of wedlock. Most of the 1,333 teenaged mothers who gave birth to a baby when they were mar- ried only legalised the babies when they were already "on the way" . Ex- perience over many years show that such marriages very frequently end in divorce, and thus only result in an increasing number of children growing up at a disadvantage compared with those from a stable family. The Hungarian Government passed a decree in 1973 making it mandatory for schools to introduce courses in family life. It was felt that young people cannot be expected to discover by themselves all that medical science Teenage mothers-to-be in a Hungarian clinic. School classes in family life try to ensure that all babies are born "healthy and wanted," and that all youngsters know about the risk of STDs. Photos WHOfT. Urban and research have determined as most likely to protect the health of the unborn child and to encourage a stable family life. The fact remains that today's young people need to be understood and helped appropriately. The present author, as a doctor and staff member of the Hungarian youth press, has sized up the level of young people's knowledge of and interest in sexual life, on the basis of over 20,000 letters written to him, and has endeavoured to provide answers to their problems in his books. So too have more than 30 Hungarian professional writers, quite apart from well-known foreign authors. Since the government decree was published, the Hungarian writers alone have produced about 50 works in an effort to serve the common goal: that healthy and wanted children should be born in stable and happy families! • 29 AIDS Increases Among Addicts in Europe The number of European countries reporting the dreaded Acquired Immunodeficiency Syndrome (AIDS) increased from 16 to 27 in a year, figures at the end of September show. And cases rose from 1 ,573 to 3,127 "with a particularly strong increase in the proportion of intravenous drug addicts among cases reported" . Photo: WHO/E. Mandelmann Spread through blood: more drug addicts are AIDS victims. According to a wHo report, the number of drug addicts in- fected by contaminated blood through sharing the use of un- steri li sed needles intravenously has trebled. In Italy and Spain alone over 70 per cent of al l cases were reported from this risk group. The report also shows: • That over 90 per cent of vic- tims were males, 63 per cent between ages 20 and 39 years, • That of all victims 73 per cent were homosexuals or bisexuals, and that over 1 0 per cent were drug addicts, I Dawdling with AIDS I This is the headline of an editorial carried recently in the New York Times, charging that "very little is being done " to curb the AIDS epidemic in the United States. The paper underscores this point in a question-and-answer fashion : Question: "Why not teach prostitutes and their customers that. the use of condoms helps block the virus's transm iss ion?" Answer: "Because that would condone prostitution." Question: "Why not educate intravenous drug abusers about the risk, provide more drug treatment centres and supply clean needles in an effort to retard the vi ru s's transmission on dirty syringes?" Answer: "Because that would sanction drug-abuse." Question: "Why not tell (young children) how, if they must experiment (with drugs or sex), to avoid AIDS?" Answer: "Because many parents don't want their children educated in either subject." Even though the "possible socia l remedies to prevent AIDS offend, law, custom or morality," the Times urges an increase of fund s for information and education targeted at high-risk groups. "That is a lot more practical than waiting for a miracle from the research laboratories," it concludes . •••••• ••••••• ••• ••• ••• •••••• •••••• ••••• • ••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••••••• ••••••• ••• ••• ••• ••••••• • ••••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• ••••••• ••• ••• ••• • •••••• ••• ••• ••••••• ••• ••• ••• ••••••• • •••••••••••••••••••••••••• ••• ••• ••••••• ••• ••• ••• •••••• • •••••••••••••••••••••••••• ••• ••• ••• ••• ••• ••• ••• ••• • ••••••••• 0 •••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • •••••••••••••••••••• ••• ••• ••••••• ••••••••••• ••••••• ••• • ••••••••••••••••••• ••• ••• ••••••• •••••••••• •••••• ••• • ••••••••••••••••• • That the Federal Republic of Germany, France and Italy, "with an average of six to ele- ven new cases per week," were countries with the great- est increases, • That 1 , 1 03 AIDS patients have died so far. AIDS is spread by sexual con- tact. blood, and birth-in the last instance, the virus is passed from infected mothers to chil- dren before, during or after birth. As there is no treatment, nor a vaccine in sight against the disease, AIDS can only be prevented through dissemina- tion of information that is aimed particularly at high risk groups and at health officials. Here are guidelines published by WHO for preventing AIDS and infection with the virus (LAVI HTLV-111, now known as HIV): To prevent spread by sex: Do not have intercourse with mul- tiple partners, nor with those in high risk groups, notably homosexuals or the promiscu- ous. Do not engage in ana l inter- course. Use a condom. To prevent spread through blood, or blood products: Steril- ise needles and syringes each time before use ; this applies as well to all instruments that pierce the skin. Check blood donations for the AIDS virus. Treat blood products, such as those used by haemophiliacs, so as to destroy the virus . Take blood transfusions only when essential. To prevent spread from mother to child: Advise in- fected women of the risk of pregnancy. • No Lectures At Maastricht Medical School AIDS Transmission There are no courses nor lec- tures facing medical students at Limburg University in Maas- tricht, Hol land. Instead the phy- sicians-to-be face "problem solving" virtua lly from the first year of their studies - and a great number of tests. • Transmission through: - intimate sexual contact with an infected individual - infected blood and blood products - infected mother to chi ld - contaminated, unsterilised syringes and needles - donation of infected body organs, other tissues or sperm. • No documented transmission through : - casual/social contact - food or water - ai rborne or faecal/oral routes - blood-sucking insects. Part of WHO's information and education material. 30 The classical manner of teaching anatomy, biochemis- try, pharmacology, physiology and the like is described by Dean Jacobus Greep as a "spoon-fed system" that pro- duces the "inflexible super-pro- fessors, and their groups and their research ." As Limburg 's medical school is oriented towards primary health care needs of the com- munity, the focus in the class- rooms is on day-to-day medical complaints . Students are exposed to medical knowledge through a " matrix method ", through which professors from specific disciplines-at Limburg, the preferred term is "capacity group" - address specific clini- cal problems. A participating anatomist, for instance, doesn't lecture just for the sake of anatomy but to solve a problem. Professors of sociology, psy- chiatry and economics are nor- mally a part of the group, which also looks at problems in the broader context of the health system and of health policy. "Despite the chilly reaction of the medical establishment, the matrix concept is apparent ly spreading," says David Ehrlich, a science writer based in Gene- va, in reporting on the Limburg experiment. "Many students from other universities sit with the new breed for examinations - and are often out-scored." Schools like Limburg, in both developed and developing countries have set up a network to exchange knowledge and ex- periences in their search for a type of health worker respon- sive to community needs. • $128 Billion Programme for Africa Proposed The Special UN General As- sembly that recently supported the African-proposed, develop- ment programme for Africa was the first-ever session devoted to just one region, thus attest- ing to international recognition of the gravity of economic prob- lems affecting its people. During a week-long session, delegates endorsed a massive five-year US $128 bil lion pro- gramme to revitalise Africa's economy based on what has been referred to as "Western- inspired " economic reforms. "For the first time since the mid-1970s, the phrase 'New Economic Order' does not ap- pear in an important UN docu- ment," Eugene Forson, a Ghanaian journalist, wrote in the UN's Development Forum. The proposed UN Programme of Action for African Economic Recovery and Development is based on an earlier two-volume report, "African Priority Pro- gramme for Economic Recov- WoRLD HEALTH, November 1986 ery, 1986-1990," drawn up at a preparatory meeting, which ac- cording to its chairman, Edgard Pisani of France, was "not a pledging conference but rather a meeting to plan Africa's future economic direction, with Afri- cans and not donors playing the key roles." As a result African states committed themselves to meeting about 70 per cent of the total costs, and the Assem- bly, in its final report. "to mak- ing every effort to provide suffi- cient resources to support and supplement the African devel- opment effort" Firm financial pledges were neither expected nor made at that time by the traditional donor countries. The proposed programme is based essentially on measures to improve agriculture. for which African states earmarked Photo: W HO/FAO Women: 60 per cent of agricul- tural workforce. $57 billion, and to combat drought and desertification, $3.4 billion. But it also calls for an outlay of $7 billion for the training of personnel, and for the promo- tion of literacy and adult educa- tion. particularly for women who comprise about 60 per cent of the agricultural work force. And it stresses incentives. Addressing the delegates. President Abdou Diouf of Senegal, who is also chairman of the Organization of African Unity, said that the programme should reverse trends "that have led a large number of Afri- can countries to . . desperate emergency situations." In summary, one delegate called it :·a breath of pure oxygen for our exhausted economies." • WoRLD HEALTH , November 1986 Newsbriefs e Airport Control. A 400-metre zone free of disease-transmitting mosquitos should be established around airports, according to experts from 7 5 island nations and areas of the Pacific. Such a "vector control zone" would prevent .the spread of diseases by aircraft. In 7982, for instance, a dengue fever epidemic struck Honiara, in the Solomons, following the introduction of the Aedes albopictus vector by air. "There is concern that this species may continue to spread, " warns Or Hiroshi Nakajima, Director of WHO 's Regional Office for the Western Pacific. As more and more people travel for pleasure and business, so the risk increases of the malaria-carrying anopheline mosquito being introduced in non-malarious areas of the Pacific. • In Cote d'lvoire. Of all cases hospitalised on psychiatric grounds, a study in the Cote d '/voire shows, nine per cent stemmed from chronic alcoholism and seven per cent from the use of narcotics, thus demonstrating that behavioural problems commonly associated with industrialised countries are now a Third World problem too. The study is cited in an article released by WHO's Regional Office for Africa in Brazzavil/e, on the subject of this year's World Health Day theme: " Healthy Living: Everyone a Winner. " • Mothers, Children. Extracts from a WHO fact sheet on the health of mothers and children: - Each year an estimated 200,000 women die from illegal abor- tions. Yet family planning methods, generally not available to them, would have markedly reduced mortality. - In developed countries, 68 per cent of married women of reproductive age used contraceptives, according to estimates for 7 980-87; in developing countries only 38 per cent did so. The figure for Africa was even lower: 7 7 per cent. - A daily cigarette smoked by a pregnant mother can reduce by 17.7 grams the birthwe1ght of the child Weight under 2,500 grams (5 lb 8 oz) is a threat to the baby's life. - Most infants need nothing but breast milk for the first four to six months of life to ensure good health. • ORS: Just a Half of Needs. With production doubling between 1983 and 7985, Third World countries are producing about a half of all the oral rehydration salts now used in the fight against diarrhoea! diseases. But even though world-wide production reached 270 million packets in 7985, according to a recent issue of WHO's Essential Drugs Monitor, that is still less than half of total needs of developing countries. UNICEF is the major external supplier of ORS, providing 30 per cent of salts imported to developing countries. it supplied about 7 50 million packets to some 70 countries over the two years. Commercially produced salts accounted for 7 5 per cent of imports. - In a related development, Or Halfdan Mahler, WHO's Director- General, told participants at the 2nd International Conference on Oral Rehydration Therapy, held in Washington, D. C. that " the use of these salts has saved at least 200,000 lives this year". • People. Appointed as Director, WHO 's Division of Public Information and Education for Health, which now reports to the Director-General : Or Hakan Hellberg (Finland), formerly in charge of coordination of strategy to achieve the goal of " Health for All by the Year 2000. " He is now responsible for these units: health education, media, and programme support. - Retired.after 30 years of international work; Mr Jack CS. Ling (China) twice director of UN in formation services; since August 7 982, D1rector of WHO 's Division of Public Information and Education for Health, and before that, Director of UNICEF's Information Division, New York. He is now visiting professor of communication, University of Southwestern Louisiana, Lafayette. - Appointed as Director, Strategy Coordination of WHO's "Health For All" programme, Or Sumedha Khanna (India), formerly Associate Director. In the next issue Safe water is crucial for development The December issue of World Health exami nes the International Drinking Water Supply and Sanitation Decade, now at its half-way point, and the efforts being made to bring safe water to the whole world. Authors of the Month Dr George ANTAL as just retired as Chief of WHO's Programme of Sexu- ally Transmitted Diseases. Dr A. 0. OsoBA is Professor and Head of the Department of Medical Microbiology at the University Col- lege Hospital , Ibadan, Nigeria, and Dr B. 0. 0GUNBANJO is Senior Lec- turer and Consultant at the Depart- ment of Microbiology and Parasitol- ogy, University of Ilorin Teaching Hospital , Jlorin, Nigeria. Mrs Maggie JoNES was formerly a staff writer for People, the magazine of the International Planned Parent- hood Federation, and is still a regular contributor to that journal. Dr Jonathan MANN is Responsible Officer for WHO's Control Pro- gramme on AIDS. Dr Gavin HART is Director of Sexu- ally Transmitted Disease Services, the South Australian Health Com- mission, Public Health Service, in Adelaide. Dr Fernando ZACARIAS is Adviser on STD Control at WHO's Regional Office for the Americas, and is based at the Centers for Disease Control in Atlanta, USA. Dr Andre MEHEUS is Professor of Epidemiology and Medicine at the University of Antwerp in Belgium. Dr Herbert NSANZE is a WHO Consul- tant based in Fiji, where he is teach- ing microbiology at the University of Fiji. · Dr Georges CAUSSE has now retired from WHO where he was formerly in charge of the Programme of Bacte- rial and Venereal Infections. Dr Pal VERES is a Hungarian physi- cian and journalist. His regular col- umn on health and sex education is widely read by young people throughout Hungary. WORLD HEALTH For readers everywhere 1986 Subscription Rates One year · Two years Three years US$ Sw. fr. 12.50 25.- 22.50 45.- 30.- 60.- ORDER F=ORM Please enter my subscription to "World Health" as follows: One year 0 Two years 0 Three years 0 I enclose cheque/international postal order in the amount of: _ ___ _ Name: _ _____ ____ _ Street: __________ _ City: ________ __ _ Country: _________ _ World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland World Health is also distributed through the network of international bookstores and sub- scription agencies. For payment in national cur- rencies. please contact your usual bookseller. Three healthy generations in an Indonesian village. Unfortunately, some sexually transmitted diseases can pass from mother to child. See page 22. Photo WHO/J . Ling
Всемирная организация здравоохранения (ВОЗ / WHO) · Journal articles
World Health: the magazine of the World Health Organization: November 1986 [full issue]: healthier sex
Открыть оригинал документа
Полный текст размещён на сайте публикующей организации. lawenc.com индексирует метаданные и ведёт на официальный источник.
Вернуться к постатейному просмотруПолный текст