EPIDEMIOLOGY IN V.D. CONTROL- PART I
by Maj. M. P. Vora, Bombay.
The Indian Practitioner
A Journal Devoted to Medicine, Surgery and Public Health.
Volume no. XXXII, Number – 6 of June 1979.
Page No. 311 to 314.
* Paper read at the III National Congress for Sexually Transmitted Diseases, New Delhi, February 1979.
WHEN the natural course of an untreated syphilis is considered, the syphilis epidemiology as a rational and effective means of syphilis control becomes crystal clear. A healthy person catches syphilis usually by sexual contact with an infectious syphilitic partner. Treponema pallida penetrate the skin or mucous membrane, multiply and spread throughout the body, weeks before the development of the clinical or serologic evidence. This is called the incubating pre-primary stage of syphilis. About 3 weeks to 3 months after the day of infection, the primary sore at the point of inoculation of germs and a positive blood serologic test for syphilis are likely to be present. The primary sore is usually located on the genitalia or any site on the body and depends on the size of the inoculation, its virulence, the pre-infection status of a person and variations in sexual practice. A small inoculum in a non-immune person produces a dark-field positive sore or only a popular lesion, followed by the sero-positive visible syphilis; but in an immune person with previous history of syphilis, even a large inoculum produces no response at all or a dark-field negative papule with sero-positive latent or concealed syphilis. The primary sore contains T. pallidum and persists for 2 to 6 weeks ordinarily. It is, therefore obligatory to think of syphilis in the evaluation of a genital lesion, whether it is trivial, atypical or dark-field negative. The VDRL test is negative as a rule in the pre-primary stage and in nearly one-third patients with an early primary stage. As a non-specific regain antibody test, VDRL is not as sensitive and reliable as the specific antibody test FTA-ABS, TPI, TPHA or ELISA in the evaluation of primary, early latent and late syphilis. These specific tests are unfortunately not designed for screening and are not freely available in our country.
Adequate penicillin G given intramuscularly during the incubation period can prevent the development of clinical manifestations of syphilis and the spread of infection to uninfected persons. Such a procedure can also provide a protection against re-infection for a short period of time. If a person with early syphilitic chancre is brought under medical care and treated adequately, the treatment itself will provide a disease control and prevent further transmission of the disease. The chances of spread of infection can thus be pre-included theoritically.
Basically, the syphilitic epidemiology involves prompt interviews of all recently infected and infectious cases to determine the sources and possible spread of infection. It necessitates obtaining from the initial case, the names of all sexual contacts, suspects and associates who constitute a high risk group of potentially infected persons between the ages of 15 to 35 and who must be quickly located, interrogated and referred to medical examination and treatment- either therapeutic or preventive. An interview of early syphilitic person discloses an average three sexual contacts at risk and at least one of the two contacts is invariably syphilitic in an infectious stage. The importance of tracing sexual contacts of patients with syphilis less than 2 to 3 years’ duration, who are highly contagious, will be obvious. The identification and treatment of all recently exposed sexual contacts is an important aspect of the disease-control programme. Equally important is the routine blood serologic screening for syphilis of high-risk groups, person who have frequent sexual exposures to two or more individuals, employees, service, personnel, industrial workers, drivers, conductors, persons undergoing medical examination or aspiring for admission into hospitals etc. Male homosexuals who are often without symptoms and cause sporadic outbreaks of syphilis deserve a special attention.
The process of epidemiology starts with the report of a new case of syphilis and is inter-related with other methods of detecting cases; the follow-up of persons with reactive serologic tests of syphilis, obtaining particulars of individuals seen and diagnosed by private medical practitioners, reports of screening done in family planning, gynaecologic and health centres, reports from laboratories and prompt communication or exchange of information system etc- all these are closely related and help to expand the epidemiologic process. The old concept of V.D. clinics as centres of activity has to be changed. It is essential to integrate antivenereal activities into general health services, hospitals, primary health centres etc. Let everyone, who provides medicare, participate in the programme to extend and accelerate control and achieve speedy results. Proper standards of medical education and training in V.D. for medical students are implicit in this concept.
In theory, syphilis can be aborted by adequate amount of penicillin given during the incubation stage of syphilis and additional syphilitic infections can be prevented by treatment of individuals early in the primary and secondary stage of syphilis. If all cases that report daily are diagnosed and treated promptly, all sexual contacts are quickly located, examined and given preventive and curative therapy for those who are incubating or having the disease respectively, this would certainly control further spread of syphilis. When these basic principles are put into actual practice everywhere, syphilis can be controlled effectively. To be successful, they must be applied on a nation-wide basis with speed, thoroughness and consistency. Any delay in application will offer opportunities for the spread of infection. The procedure involves a provision of trained personnel to interview patients, a reliable and prompt laboratory service, full co-operation of medical men and a dependable system of prompt exchange of information to ensure quick action. Application, extension and execution of the procedure with zeal at all levels of health services in the state and in the country can result in convincing success. The most productive and rewarding procedure is that which leads to the treatment of contacts in the incubating pre-primary stage.
Syphilis epidemiology, which aims at breaking the chain of transmission of syphilitic infection can be reliable, effective and highly rewarding, if all doctors would use it diligently and vigourously, in their daily practice everywhere. A positive approach to the new concept, its wide acceptance and application are of crucial importance. Neglect in contact-tracing is the major factor responsible for continuation of syphilis. The necessary tools for the control of syphilis are freely available but they are unfortunately not being applied and extended all over the country in the most effective manner. Who can be blamed for the present deteriorating and alarming situation?
Suggested Treatment Schedules
Pre-primary stage- 2.4 M.U. Benzathine Penicillin G or PAM I.M. at one session in two injections.
Primary and early secondary state – 4.8 to 6.00 M.U. of Benzathine Penicillin or PAM I.M. in divided doses in 4 to 5 injections on alternate days or Aqueous Procain Penicillin G 600,000 units I.M. daily for 15 days.
In case of penicillin sensitivity – Erythromycin estolate or Tetracycline HCL orally 2 gm. daily in divided dose for 15 days.
All cases must have subsequent follow-up physical and serological- for a sufficient time to confirm ‘Cure’.
EPIDEMIOLOGY IN V.D. CONTROL- PART II
by Maj. M. P. Vora, Bombay.
The Indian Practitioner
A Journal Devoted to Medicine, Surgery and Public Health.
Volume no. XXXII, Number – 6 of June 1979.
Page No. 317 to 320.
GONORRHOEA EPIDEMIOLOGY is another major segment of V.D. Control, designed to interrupt the chain of transmission of Neissarian gonococcus infection by interviews, contact-tracing, screening for gonorrhoea and treatment to cure the disease.
Neissarian gonococcus, which has the special affinity for the columnar and the transitional epithelium, is the causative organism. A person who has the disease, transmits germs to the healthy partner during sexual relations. The incubation period is generally 2 to 3 days, although extremes of 10 to 14 days have been recorded in some cases. The clinical picture depends on the mode of sexual practice, anatomic site of the inoculation, the quantum and virulence of germs, the stage of the disease and the presence and absence of local and systemic complications. The primary site of infection may be the urethra, anal canal, pharynx, cervix, endocervix, the duct of sex-gland or conjunctiva. Contrary to the widely held impression, the onset of the disease is often insidious and without symptoms in nearly 20 per cent males and 80 per cent females. Ano-rectal and pharyngeal involvement in homo and hetera-sexuals is inconspicuous and often lacking in symptoms. The infection of the cervix and the endocervix in the female can be symptomless. Concurrent syphilis is a real possibility in some 5 percent cases. Since most individuals with symptoms are likely to seek medical advice and treatment, asymptomatic men and women, who are usually chronic sufferers or incubating carriers of gonococci, comprise the great reservoir of inapparent infection in the community. When the patients with symptoms are interviewed to determine their sources and contacts, whether the male or the female, they (contacts) are usually without a complaint or a symptom. Because these persons do not suspect the disease, go untreated and to continue sexual relations, they represent a greater potential for unknowingly spreading the disease rather than their counterparts with symptoms. The disease is frequently suspected or recognised in them only when serious complications develop.
A true epidemic of gonorrhoea is sweeping the country and the world; the most important reasons are: the omission of contact-tracing, which is an integral part of V.D. management, abandonment of condom as prophylaxis against V.D. following the introduction of oral or I.U. contraceptives, disregard to carry strict criteria of cure after therapy, insufficient or inefficient treatment, development of drug resistant strains of germs, high rate of re-infections because of the speedy, safe, affective modern therapy and an increase in sexual activity and promiscuity.
An individual, when identified as suffering from gonorrhoea is interviewed in strict privacy concerning his or her sexual contacts, who are then located, interrogated, examined and treated with speed and thoroughness, to prevent the spread of infection. In this preventive epidemiologic approach, persons are treated as soon as they are known to have been exposed to the risk of infection, i.e. long before they actually developed the clinical disease, thus eliminating the possibility of their being sources of further spread of infection. The principle objective here is to identify and treat gonococcal infection both in the male and the female, whether they are with or without symptoms. An experienced interviewer of a symptomatic patient can easily identify and bring to treatment at least 2 to 3 additional cases for every person interviewed. Patients are made to feel that they are an extension of local health service and are encouraged to play a vital role in stemming the spread of infection. It is now possible to locate persons with gonorrhoea, by routine interviews and screening programmes. Since laboratory tests commonly employed to determine the gonococcal etiology, (Gram-stained smear and culture), are not hundred per cent sensitive to pin-point the disease at the first examination in all persons, it is, therefore, advisable to treat all the recently exposed persons, irrespective of clinical signs and symptoms or the positive smear or culture or a combination. An appropriate preventive or curative treatment at the very first examination must become a matter of routine for sexual contacts of gonorrhoeal cases. This epidemiological treatment is the most effective and reliable in the control of the cyclic spread of infection from the symptomless and unrecognised persons, specially between the ages of 15 and 35. After the therapy, careful follow-up tests of cure over a certain period of time are mandatory in every case. It would be unwise to assume that a patient with gonorrhoea is cured because he or she has received an acceptable treatment.
Since a large number of cases is to be dealt with daily, it is expedient to decide guide lines and priorities and determine efforts and resources to obtain the maximum yield, in terms of new infections discovered. This will ensure best returns for resources expanded on gonococcal epidemiology per a new case detected. Sufficient stress must be laid on voluntary or person’s own initiative for the diagnostic screening at various centres of health or medicare. Unquestionable is the urgent need to integrate this work into general health services and to provide quick and reliable laboratory services. Three interview categories in order of effectiveness to yield new or untreated cases are:
Interviews with all these categories are valuable and productive but those with the volunteer males are the most productive and the least expensive of all in the discovery of new cases.
The efficacy of gonococcal epidemiology as a case-detection procedure and the disease- control measure is in no dispute or doubt. When the male volunteers are interviewed and their female contacts are brought for medical examination, nearly 20 per cent of the contacts are symptomatic with unequivocal clinical evidence of disease, while 80 per cent are without symptoms and nearly 50 per cent of them require treatment at the first examination for the previously untreated and undiagnosed gonococcal infection. Among the male contacts of the female with gonorrhoea, nearly 60 per cent are symptomatic while 40 per cent are asymptomatic at the time of examination with positive smear or culture and are in need of treatment. It is, therefore, very urgent and imperative to improve and refine techniques for the detection of gonococci, use them routinely, encourage people to seek prompt medical examination voluntarily and bring their sexual contacts with them, whenever signs and symptoms of the disease are suspected or evident, following sexual encounters.
The most effective measures now available for the control of gonorrhoea are the routine diagnostic screening for the asymptomatic disease and treating the sexual contacts of persons with gonorrhoea on the basis of verification or suspension. This is the most realistic approach in preventing the spread of gonorrhoea and achieving its global control. The concept of epidemiologic control of gonorrhoea is quite reliable and needs a continued appreciation and wide-spread application in view of the present epidemic.
Suggested Schedules or Treatment for Fresh and Uncomplicated Gonorrhoea
1.5 gm. stat and 1.5 gm. at bed time on the 1 st day. Then 2 gms. per day in divided doses for 3 days.
6. 1.00 gm. Doxycycline in 4 days orally: -
200 mg. stat and 200 mg. at bed time on the 1 st day. Then 100 mg. twice a day for 3 days.
7. 1.00 gm. Minocycline in 4 days orally :-
200 mg. stat and 200 mg. at bed time on the 1 st day. Then 100 mg. twice a day for 3 days.
8. SMT – TM (‘Septran’ or ‘Bactrim’) 3 to 4 tablets twice a day orally for 4 days.
All cases must have subsequent follow up- physical, serologic and bacteriologic – to confirm cure i.e. eradication of organism and exclusion of syphilis.
Summary – Part I and II
V.D. control can be highly effective and entirely successful when epidemiologic procedures are applied energetically and universally. Early recognition and aggressive management of venereal diseases is the keystone of success. Medical practitioners have in fact the capacity to make the national V.D. control programme a notable success, as the treatment to cure V.D. remains the most powerful weapon against the spread of venereal diseases. Nevertheless, they must not ignore to find the source and contacts of their patients and deal with them promptly. The supreme leadership rests with them for the effective and rapid action all over the country. Will they take up the challenge? A sufficient evidence of the out-standing success is available in Himachal Pradesh, where doctors have understood the fundamental concepts and utilized them ably in the programme of activity. An average patient must be made to feel that he or she is being looked after well and is expected to derive maximal benefit from the care provided. The goal must be early discovery and treatment to cure V.D.