Syphilis and gonorrhoea have company / by A. O. Osoba and B. O. Ogunbanjo

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