Yaws eradication programme

YAWS

1. Yaws eradication programme APARNA .M .AJAY ASST.PROFESSOR

2. Yaws  is a chronic infection that affects mainly the skin, bone and cartilage. The disease  occurs mainly in poor communities in warm, humid, tropical areas of Africa, Asia and Latin America. The causative organism is a bacterium called Treponema pertenue , a subspecies of Treponema pallidum that causes venereal syphilis.

3. Yaws: The long challenging path towards eradication   India has achieved breakthrough public health milestones in the past by eradication of smallpox and guinea worm disease.  There has been a concerted effort to target other diseases in the country which are amenable to eradication/elimination. One such disease, yaws has been the target since decades and particularly after the inception of yaws eradication programme (YEP) since 1996-97.

4. Epidemiology   Yaws belongs to a group of chronic bacterial infections (endemic treponematoses , non-venereal spirochete diseases) caused by treponemes . The organism responsible for yaws is Treponema   pallidum  subspecies  pertenue . It is morphologically and immunologically identical to T.  pallidum  (the organism that causes venereal syphilis).

5. Other diseases belonging to this group are bejel (endemic syphilis) and pinta . Yaws is the most common among these three and occurs primarily in the warm, humid and tropical areas of Africa, Central and South America, the Caribbean, Indian peninsula and the equatorial islands of South-East Asia.  

6. It is usually prevalent among the people living in primitive, unhygienic conditions in hot and humid areas like those found in tropical countries.

7. In India, this disease was seen among poor, most marginalized and difficult to reach population living in remote, hilly, forested areas of the country and particularly affected the tribal population. 

8. The infection put these marginalized population at a further disadvantage because of morbidity, disability & economic burden associated with the disease

9. Mode of transmission Yaws is transmitted by direct (person-to-person) contact with the exudates and serum from infectious lesions. The total duration of infectiousness for an untreated yaws patient, including relapse is probably of the order of 12-18 months.

10. Clinical manifestations After the bacterium has "penetrated" into the skin, within a period of 3 to 4 weeks (with a range from 10 to 90 days), early lesion appears near the infection. Early secondary lesion appears usually after an interval of 6-16 weeks (or even upto 2 years) of the primary lesion. 

11. Yaws most commonly occurs in young children is characterized by a primary skin lesion (Early Yaws). It starts as a small papule, but reaches up to 5 cm in diameter, becomes lifted, is often ulcerated, and may resemble a raspberry. 

12.   Papilloma is the most common presentation and is often pruritic facilitating spread of the infection to other areas of the body by scratching. These lesions may persist for 3-6 months and heal spontaneously, often leaving a scar.

13. The early secondary skin lesion is papular and may occur any time from 4 to 12 weeks after the initial infection.

14. The rash covers the limbs, neck, and buttocks and may spread onto the body. It is at this stage that the serological tests become positive. 

15. Nocturnal bone pain and tenderness of the tibia and other long bones due to periostitis are common and may persist for up to 6 months.

16. Usually after 5 years of onset of illness, destructive lesions of the skin, bone and cartilage (Late yaws) may appear which are non-infectious but may result in disabilities like gangosa and pathological fractures.

17. Yaws simulates the lesions of scabies, impetigo, skin tuberculosis, tinea versicolor , tropical ulcer, leprosy and psoriasis. The yaws may also coexist with any of these lesions. There is no natural immunity.

18. Diagnosis Most latent and incubating cases are found in clusters around an infectious case and can usually be diagnosed by epidemiological tracing. Serological tests to detect treponemal antibodies can be useful in diagnosis of yaws only if sexual transmitted syphilis is excluded ..

19. In field situation, these tests support a clinico -epidemiological diagnosis of yaws but are not as specific as the dark-field examination.

20. Commonly used tests are Venereal Disease Research Laboratory (VDRL) test and the rapid plasma reagin (RPR) test which are inexpensive, rapid and simple to perform. It takes time for sero -positivity to appear after the onset of disease and hence, initial (mother) case may be sero -negative

21. Sub-species of  Treponema pallidum , i.e.,  Treponema pallidum subsp.  pallidum ,  Treponema pallidum   subsp.  pertenue , and  Treponema pallidum   subsp. endemicum   cannot be serially cultured in vitro, are   indistinguishable by dark-field microscopy.

22. However, sub-species specific   genetic signatures permit molecular differentiation using methods that   involve polymerase chain reaction (PCR), restriction fragment length   polymorphism (RFLP) and DNA sequencing of specific treponemal DNA sequences

23. . Real-time polymerase chain reaction (RT-PCR) has been proved to be very efficient in molecular differentiation among all subspecies of treponemes . It is very fast, highly sensitive and highly specific assay.

24. Treatment Single dose of injection benzathine benzyl Penicillin was the treatment of choice for both cases and contacts of yaws.

25. In patients allergic to penicillin, erythromycin/ tetracycline was the alternative treatment of choice and India used the same treatment to counter the disease. However, off late WHO recommends use of single dose of azithromycin as the preferred treatment of choice.

26. Yaws: Global Overview Since the creation of WHO in 1948, the fight against endemic treponematoses (yaws, bejel and pinta ) has been a priority for the Organization. 

27. A review of historical documents from the 1950s, shows that at least 88 countries and territories within the tropical belt of 20 degrees north and south of the equator were endemic for yaws. Published reports suggest presence of yaws in many parts of the world viz

28. . South East Asia (India, Indonesia, Timor-Leste, Thailand, Sri Lanka), Western Pacific (Solomon Island, Papua New Guinea), Africa (Congo, Ghana, Ivory Coast, Togo), PAHO (Haiti, Eucador ) etc

29. In the period 1952-1964, WHO in close collaboration with UNICEF, launched the global endemic treponematoses control programme (TCP), which became a real success story. More than 50 million patients were treated in 46 countries, reducing the overall prevalence of these diseases by more than 95%.

30. The control strategy subsequently changed from a vertical programme to be integrated into the basic health services. These basic health services were to cope with the remaining “last cases” of endemic treponematoses in the community until eradication has been achieved.

31. The goal of eradication was not attained due to the complacency following gradual dismantling of the vertical programmes & premature integration of yaws control activities into weak/ non-existent primary health-care systems in yaws endemic areas and disappearance of the resources and commitment for yaws control. 

32. A number of foci of transmission remained and by the end of the 1970s a resurgence of the endemic treponematoses had occurred in many areas of the world.

33. The necessity for renewed efforts was recognized by the World Health Assembly and expressed in WHA Resolution 31.58.

34.  In 1995, WHO estimated that 460,000 infectious cases of yaws occurred worldwide: 400,000 in West and Central Africa; 50,000 in South-East Asia and the remainder in other tropical regions.

35. Yaws: Indian scenario In India, there was a paucity of literature on yaws. Reports suggest that the first cases of yaws were reported from among tea plantation workers in Cachar district of Assam in 1887. The disease was later detected in states of Orissa, Chhattisgarh, Madhya Pradesh and other areas .

36. In India, the disease is mostly known by the name of the tribes which are mostly affected by yaws in any region. For example, the disease is called ‘ Madia Roga ’ and ‘Gondi Roga ’ in Maharastra and Madhya Pradesh.

37. Some synonyms of yaws are based on its clinical features e.g. it is called ‘ Domaru Khahu ’ in Assam which indicates a fig like eruption. ‘ Chakawar ’ is a term used for chronic ulcers so commonly seen in Central India and part of Uttar Pradesh.

38. The disease was reported from the communities living in hilly and forested areas in the tribal inhabited districts in states of Chhattisgarh, Odisha , Andhra Pradesh, Telangana and Maharashtra

39. . Madhya Pradesh, Tamil Nadu, Assam, Jharkhand, Uttar Pradesh and Gujarat are other states from where cases had been reported earlier.

40. During 1952-1964   mass campaign were launched with assistance from WHO and UNICEF in the States of Orissa, Madhya Pradesh, Maharashtra, Andhra Pradesh and Madras (now Tamil Nadu) and about 0.2 million cases were detected from these states.  

41. The strategies adopted were house-to-house survey in the villages to identify cases followed by selective mass treatment of all cases, their household and other contacts with a single injection of PAM (Penicillin G in oil with 2% aluminium monostearate ). This resulted in marked reduction of yaws cases in India and disease prevalence was brought down from 14.0 per cent to below 0.1 per cent in many areas

42. . Following this dramatic decline in disease transmission, active anti-yaws activities were abandoned in the majority of the States. In 1977, yaws resurgence occurred in Madhya Pradesh.

43. In 1981, the National Institute of Communicable Diseases (NICD), Delhi undertook a rapid survey to assess the situation; wherein A total of 18,196 individuals from three districts of Orissa, one district of erstwhile Madhya Pradesh, Maharashtra, Andhra Pradesh were examined and twenty-six cases were detected, six of them serologically positive, indicating  continuing yaws transmission in some areas of the country.

44. In 1985, NICD collected information using mailed questionnaire method from various districts of five states (Andhra Pradesh, Madhya Pradesh, Orissa, Maharashtra and Tamil Nadu).

45. The data suggested that problem of yaws continued to linger on in India albeit at a low level.

46. In 1995, NICD prepared a project document on Yaws Eradication Programme in India, which was approved by Government of India for initiating the yaws Eradication Programme

47. (YEP) in Koraput district (undivided) of Orissa and was then expanded to cover all the eleven yaws endemic states of the country.

48. objectives of the programme were to achieve: v  Cessation of transmission of yaws in the country (defined as nil reporting of new yaws cases) and v  Eradication of yaws defined as absence of new cases for a continuous period of three years, supported by absence of evidence of transmission through sero -survey among under-five children (i.e. no sero reactivity to RPR/VDRL in <5 yr children ).

49. The programme strategy adopted to achieve these objectives: ·    Creating yaws consciousness and awareness in health professionals and community members, ·    Trained manpower development, ·     Detection and treatment of cases and contacts, ·     Monitoring and evaluation, and ·     IEC activities harnessing multi- sectoral approach.  

50. A high-level National Task Force (NTF) was established under the chairmanship of DGHS for undertaking periodic reviews and for monitoring the progress in implementation and to advice on Annual Plans of the action.

51. The programmes was subjected to independent appraisal frequently and in all Six Independent Appraisals of the programme were undertaken since the beginning of YEP.

52. After years of continuous fight against yaws, the last case was reported in India in October, 2003.

53. The Zero incidence of yaws cases was validated by eminent experts and based on recommendations of the task force the disease was finally declared as eliminated by Honorable union health & FW minister at Vigyan Bhawan on 19 th September 2006.

54. Journey from Elimination to Eradication Subsequently, India embarked upon the journey for eradication of yaws from India. In post elimination phase apart from ongoing activities three new activities were started: ·          Sero -survey among children to assess cessation of transmission of infection for 3-5 years ·          Rumour reporting  ·         Investigation and cash incentive scheme to encourage voluntary reporting of the cases by the community.

55. Based on the recommendation of the sixth independent appraisal, the seventh Task force meeting on YEP under the chairmanship of DGHS on 25th July, 2014 recommended seeking Yaws eradication status for India.

56. Following this WHO was approached for certification of Yaws eradication. In this context, WHO sent an international Verification team (IVT) of experts for assessment of yaws free status of India during 4–17 th  October, 2015..

57. Based on the recommendations of the IVT, WHO Director General declared India free of Yaws at Geneva on 5th May, 2016. A celebratory function was organized to mark the end of Yaws from India on 14 th  July, 2016 at National Media Center, Raisina Road, New Delhi

58. The Honorable Union Health and Family Welfare minister Mr. Jagat Prakash Nadda was the Chief Guest and Honorable Minister of State for Health and Family Welfare,  Ms. Anupriya Patel was the Guest of Honor in the event ..

59. Several other dignitaries including the Secretary (Health and Family welfare), Director General of Health Services, Regional Director of WHO South East Asian Region, Additional Secretary (Health) and Mission Director National Health Mission, Director NCDC and Mr. James from UNICEF graced the occasion.

60. The function was also attended by officials from the ministry of health and family welfare, Govt. of India and special invitees from local administration, district & state health officials and NGOs working in the erstwhile yaws endemic states in India

61. The Honorable Union Minister of Health and Family Welfare formally declared India as free of Yaws in presence of the august gathering in the function. 

62. He lauded the dedicated and concerted effort of health authorities of endemic states/districts in implementing and monitoring the Yaws Eradication Programme under the able leadership of the National Centre for Disease Control, the national nodal agency for the Yaws eradication programme .

63. The dignitaries also released a monograph titled “YAWS DISEASE-END OF SCOURGE IN INDIA”. The Union Health Minister expressed his gratitude to all who worked tirelessly to make the endeavor of yaws eradication a reality. Declaration of yaws Free India (14 July, 2016)

64. 10 facts on yaws eradication June 2016 Yaws is a chronic infectious disease that is closely linked to poverty. It is eradicable as humans are the only hosts.

65. A global campaign using benzathine penicillin injection reduced 95% of global cases in the late 1960s. However, abandonment of programmes and weak surveillance led to resurgence in many countries, prompting WHO to re-start control programmes in 2007.

66. The discovery in 2012 that a single, oral dose of the antibiotic azithromycin can completely cure yaws has added momentum to eradication.

67. Today, only 13 countries are known to be endemic. India is the first country officially declared free of yaws by WHO in 2016.

68. Facts of yaws eradication

69. Tackling a postwar public health 1948-1958 When WHO established in 1948,yaws and other bacterial infections caused by treponema such as endemic syphylis bejel penta were some of the pressing public health problems it had to tackle head on.Once 50 million people mainly children were affected.

70. Fact2: Yaws begins where road ends Historically,yaw is considered as an end of road disease because people affected are mostly poor in live in difficult to access areas. Health workers faced serious difficulties in reaching affected population.

71. Fact3:start of eradication campaign in 1952 Between 1952 and 1964,WHO and UNICEF supported mass treatment campaign in 46 countries . WHO provided technical support and UNICEF gave logistical assisstance . An estimates of 300 million people were screened and over 50 million treated , reduce disease burden by 95%

72. A MAGIC TABLET THAT REVOLUTIONAZIED THE TREATMENT The development of benzathine pencillin coincided with the birth of WHO in 1948.The second world health assembly1949 adopted a resolution to control yaws.

73. 5.Health education

74. 6.Breakthrough Azithromycin as alternative to injection

75. 7.The magic tablet accelerate the path to eradication.

76. The renewed eradication strategy

77. Who certifies india a free of yaws

78. Global eradication feasible by 2020