Yaws in the periurban settlements of Port Moresby, Papua New Guinea HOPE worldwide (PNG), Port Moresby, Papua New Guinea Yaws is a re-emerging disease in Papua New Guinea. A resurgence of yaws is documented in the periurban settlements around Port Moresby. A total of 494 cases were identified from April 2000 to September 2001. The age distribution ranged from 2 years to adult (median 9 years). Presenting symptoms were adequately recorded in 286 cases (58%). Of these, 42% presented with raised painless sores, 47% with bone/joint symptoms only and 11% with both sores and bone/joint symptoms. Children in communities with a suspected high prevalence were surveyed and examined for presence of primary yaws sores. 33 out of 227 children examined (15%) had evidence of primary yaws sores. Initial control measures have been case- finding and treatment of contacts, but in areas of known high prevalence mass treatment is planned. Introduction
This spirochaete is morphologically,antigenically and genetically indistinguishable
from T. pallidum var pallidum, the causative
Guinea (PNG) before 1950. Between 1953 and
1956 an average of 16,186 cases were reported
response and clinical features (7,8).
treatment campaign from 1953 to 1958markedly reduced the incidence of yaws.
Yaws is transmitted via skin to skin contact.
Yaws became a notifiable disease in 1969 with
The role of flies and fomites in transmission is
annual reported cases remaining less than 1000
unclear. Congenital transmission of yaws does
per year until 1978. The majority of these
affecting children in communities with poor
Department of Health removed yaws from the
hygiene. It has three clinical stages. There is a
national reportable disease listing and interest
in yaws waned. However, following reported
lesion is a papule that develops into a round or
leaving no scar. This lesion has also been
Trobriand Islands (3), East New Britain, West
termed framboiesia tropica. It usually resolves
New Britain, New Ireland and West Province
of the Solomon Islands (4), yaws was re-listed
multiple secondary papillomatous lesions may
as a reportable disease in 1984 (1). In 1984,
821 cases were reported (5), in 1989, 3421
lesions include dermatitis, hyperkeratosis of
cases (6). Most outbreaks have been on the
communities. To date, no reports have been
dactylitis and juxta-articular inflammation may
published detailing yaws outbreaks in urban or
particularly at night. Chronic effusions mayoccur in synovium-lined cavities.
Yaws is an infectious disease of the tropics
caused by Treponema pallidum var pertenue.
After a latent period yaws may reappear in a
HOPE worldwide (PNG), PO Box 3478, Boroko, NCD 111, Papua New Guinea
tertiary form with necrotic destruction of skin,
coming to their block (group of houses) and
cartilage and bones resulting in gross deformity
only 21% of dwellings have electricity. On
average there are 6.8 people per dwelling. People from every province of PNG live in the
In early lesions T. pertenue may be seen on
area (10). Yaws was first observed by clinic
staff in 1995. From 1995 to 1998 there was a
exudate from suspected lesions. Diagnosis in
gradual increase in cases. During 1999 case
the field is often made on clinical grounds
Study design
Laboratories) flocculation test is a sensitivenontreponemal test. The antibody titres peak at
The first part of the study involved clinic-
about 10 months after initial infection.
based case detection at 9 Mile Clinic. Patients
Treatment interrupts the peak levels. Antibody
presenting to the clinic with signs or symptoms
levels gradually decrease to normal over 9
months to 3 years (9). Reactive VDRL tests
are confirmed by a treponemal-specific test
defined as a clinical case of yaws with a
positive VDRL and TPHA, were then noted in
haemagglutination (TPHA) test. A negative
the clinic register. The age, sex, clinical
test in a person suspected of having secondary
presentation and location of confirmed cases
yaws excludes the diagnosis. Sensitivity is
recorded. Previous studies have used a titre of
positive predictive value of a positive VDRL
positive predictive value of any VDRL titre
and a positive TPHA, it was decided to use apositive TPHA in conjunction with a positive
T. pertenue is still generally susceptible to
penicillin. Benzathine penicillin is preferred as
presentations were divided into the following:
a single dose, producing a treponemocidal
level for more than 3 weeks. It is stable in the
tropics and available in multidose phials.
bone/joint symptoms together and ‘yawsunspecified’. The patients with ‘yaws
In the Western Pacific Region a decreased
unspecified’ were those in whom clinical
response to benzathine penicillin has been
presentation was not recorded accurately.
reported (6). Tetracycline, erythromycin and
chloramphenicol would be appropriate second-
known yaws cases who were brought in for a
Study population
community prevalence survey of cutaneousyaws. This was carried out in July 2001, in
The 9 Mile Urban Clinic serves a population
of approximately 20,000 people (1998 figures)
from 8 and 9 Mile settlements. The annualpopulation growth rate is estimated to be 7.2%.
There were four survey sites; Sabusa, Keto,
However, patients also come regularly from
Lareba and Laloki. The surveys were planned
Erima, Sogeri District and communities along
in advance to coincide with ‘local government’
the Hiritano Highway (Laloki, Sabusa, Brown
day ensuring the presence of the majority of
the population. The surveys were carried out atthe local meeting area of each community.
Residents’ access to utilities is limited even
Consent was obtained from the local leaders
in the established 8 and 9 Mile settlements.
and the survey explained in both Melanesian
Pidgin and the local language. Children who
were old enough to walk up to the age of 16
from 2 years old to adult (median 9 years). Of
papules suggestive of yaws and a history taken
the 494 cases, 31 cases did not have the age
specifically asking about the presence of
bone/joint symptoms suggestive of yaws. The
remaining 463 confirmed cases is shown in
survey was carried out by the nursing and
Figure 2. Many adults in this population do
not know their age. These were recorded as
having ages greater than 20 years old. More
than 90% of all cases were between 2 and 18
The clinical presentation of confirmed yaws
Yaws cases identified were advised to come
cases is shown in Table 1. Of the 286 cases
(58%) in which there was a clear clinical
injections. Family members were also advised
raised yaws sores, 47% had bone/jointsymptoms only and the remaining 11% had
From April 2000 until the end of September
The VDRL titres of yaws cases are shown in
Table 2. In 85% of the cases the VDRL titre
identified and registered at the 9 Mile Urban
was 16 or above. All cases had a positive
depicted in Figure 1. The male to female ratioof the 486 confirmed cases of known sex was
The results from the field surveys carried
out are shown in Table 3. 227 children were
Figure 1. Number of new yaws cases by month from April 2000 to September 2001 in the periurban settlements of PortMoresby, Papua New Guinea.
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 20+
Figure 2. Age distribution of yaws cases in the periurban settlements of Port Moresby, Papua New Guinea.
examined in the four areas described. Of these,
sores amongst the children examined was 7%
33 (15%) had active yaws sores. 20 (9%) gave
a history of bone/joint symptoms suggestive ofyaws. The highest prevalence of active yaws
Discussion
sores was in Sabusa. 26 (23%) of the 112children examined had evidence of a raised
resurgence of yaws in the periurban settlements
bone/joint symptoms in response to direct
of Port Moresby, Papua New Guinea. A case
questioning. In Lareba, a different location but
series of 494 cases is documented. This is the
with similar demographics and socioeconomic
status to Sabusa, there were no yaws sores
found in the 19 children that were examined.
resurgence has been previously documented on
In Keto and Laloki the prevalence of yaws
the New Guinea Islands and in rural areas.
CLINICAL PRESENTATION OF YAWS CASES IN THE PERIURBAN SETTLEMENTS OF PORT MORESBY, PAPUA
Clinical presentation Number of yaws cases Percentage
hard to interpret as the numbers may have beenaffected by an increasing awareness amongst
VDRL TITRES OF YAWS CASES IN THE PERIURBAN
the patients and their families. Clinic staff
awareness and interest in the disease may also
have affected the results. One may expect anincrease in numbers during the dry season
VDRL titre Number of Percentage yaws cases
The age distribution of cases is similar to
that discussed in the literature. 90% were aged
between 2 and 18 years old. There may well
have been some overlap and diagnosticinaccuracies in the adults presenting with
‘yaws’ and syphilis as they both are diagnosedby a positive VDRL and TPHA. Clinically, the
The periurban settlements of Port Moresby
rashes of secondary syphilis and secondary
in 2001 provide an ideal environment for yaws
yaws in adults may also be similar. However,
transmission. There is a young, highly mobile
benzathine penicillin is appropriate treatment
and rapidly increasing population, with people
originating from throughout PNG. Otherfactors that could promote the spread of yaws
‘Yaws unspecified’ was the most common
include lack of access to water, the decreasing
classification of clinical presentation and
reflected a number of issues. Firstly, some of
immunologically naive population susceptible
these patients were symptomatic contacts of
known yaws patients who had positive VDRLtests and were treated for yaws. Secondly, due
The impact of yaws on communities is hard
to staff shortages the data entry was not always
to assess. The tertiary form of yaws can result
in grossly disfiguring, destructive lesions ofskin and bones. However, these tend to occur
10 to 15 years after the initial infection. We
was a clear clinical presentation documented,
47% had bone/joint symptoms alone, and 11%
had bone/joint symptoms in association with
yaws sores at presentation. It has been the
observation of the clinic staff that for a childfrom this area who presents with sore joints or
bones, with no history of injury and without
PREVALENCE SURVEY OF YAWS CASES AMONGST CHILDREN UNDER 16 YEARS OLD IN 4 PERIURBAN
SETTLEMENTS OF PORT MORESBY, PAPUA NEW GUINEA
Location Number with Number with yaws sores painful joints examined
WORLD HEALTH ORGANIZATION RECOMMENDED POLICY FOR YAWS
Percentage of population Prevalence of active yaws Recommended treatment serologically positive sores in community
Total mass treatment withbenzathine penicillin
Mass treatment for all juveniles<15 years old, cases and knowncontacts with benzathinepenicillin
Treatment of cases and knowncontacts with benzathinepenicillin
signs of sepsis or rheumatic fever, the likely
guidelines in that only juveniles less than 16
joints are wrists, elbows, knees and ankles.
presence in Sabusa of 23% of juveniles with
symmetrical pattern. The possibility exists,
bone/joint symptoms is an indication that yaws
therefore, that an outbreak of yaws may be
reported as an outbreak of oligoarthritis,arthralgias or ‘sore knees and ankles’.
population of Sabusa is less than 16 years old
and that 90% of yaws cases are in the younger
Technical Reports advise that in areas of
age groups, the WHO recommendations would
known endemicity the prevalence of cutaneous
suggest that a mass treatment campaign is
yaws can be used as a guide for community
indicated for the children of Sabusa. This is
currently being planned. Other areas within 8
and 9 Mile settlements, and the other periurban
guide, but is more difficult in rural areas than
surveyed to assess the yaws burden and therequirement for mass treatment.
shown in Table 4. Each community withactive yaws should be assessed annually. At
Conclusions
least 80% of the population should be assessedeach time. When <0.5% of the population has
active yaws, the mass treatment phase settles
New Guinea. The majority of cases occur in
children. Clinicians in PNG should be awarethat patients with yaws often present with
bone/joint pains in the absence of sores. Yaws
initially an attempt to control the disease with
is once again a significant public health issue
case-finding only. They were carried out in
throughout PNG. It is treated easily with a
areas thought by the clinic staff to have a high
single dose of penicillin and there are clear
guidelines regarding community assessment
relative ethnic and climatic homogeneity there
and control. Thus, yaws requires resources and
survey was not done in accordance with WHO
ACKNOWLEDGEMENTS
Report 1984. Port Moresby: Department of Health,1984.
Thanks to the nursing staff of 9 Mile Clinic
6 Meheus A, Antal GM. The endemic treponematoses:
not yet eradicated. World Health Stat Q 1992;45:
and the staff of HOPE worldwide (PNG) for
data collection and support. Also thanks to
7 Wicher K, Wicher V, Abbruscato F, Baughn RE.
Professor John Vince for wise and helpful
Treponema pallidum subsp. pertenue displays
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