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Syphilis and gonorrhoea have company by A. 0. Osoba and B. 0. Ogunbanjo •

omeone once said that in the lence of these diseases-with no re­ bean. It is one of the most serious and beginning, when God created spect for race, creed or status-in both deadly of the STDs, and most cases Adam and Eve, He also created developed and developing parts of the tend to be sporadic and concentrate in venereal diseases, and for that reason world; and the enormity of the prob­ the towns. As with most STDs, the He admonished them not to eat the lems they generate with regard to victims are usually the sexually active, apple. But Adam did eat the apple! management and control. especially prostitutes, soldiers, sailors, Sexually transmitted diseases have More than 20 micro-organisms are homosexuals and so on, aged between always plagued humanity, but have now recognised as STD agents and never before attracted such worldwide they include viruses, bacteria, para­ attention as they have in recent years. sites and fungi. Top row: Gonococci-micro-organisms Among the reasons for this are the Venereal syphilis occurs throughout causing gonorrhoea, and the crab louse phenomenal increase in the spectrum the world, but increasingly so in areas Phthirus pubis. Second row : Candida, a of diseases and infections now desig­ where yaws used to be endemic in yeast-like fungus, causes candidosis and nated as STDs; the alarmingly high Africa, South-East Asia, the Western Herpes genitalis produces genital ulcers. and continuing increase in the preva- Pacific, South America and the Carib- Photos W HO

W oRLD HEALTH, November 1986 5 - Syphilis and gonorrhoea have company

15 and 30. Younger people are in­ countries, the prevalence of gonococ­ patients receive effective treatment, creasingly afflicted as a result of a cal infections is as high as 10.6 and they may have developed corneal per­ general early onset of sexual experi­ 18.9 per cent. foration and blindness. ence and promiscuity. These remarkably high figures have There is also a rise in the incidence The disease is usually acquired by been attributed to a rise in promiscuity of prepubertal gonococcal vulvo­ sexual contact with infected persons, which may in turn have been influ­ vaginitis especially in tropical Africa. although non-venereal contact among enced by the availability of contracep­ Direct contact with infected towels, children has been documented. Most tive pills for women, the mobility of bed-sharing with infected parents, morbidity and mortality caused by populations, and the rejection of tradi­ carelessness concerning personal venereal syphilis, especially in adults, tional morality by young people. hygiene and sexual assault are some of is due to the variable occurrence of Control has been made more dif­ the factors responsible. These factors, late manifestations of illness in the ficult by the presence of large numbers coupled with bizarre social customs skin, bones, central nervous system or of infected patients with no obvious and practices, as well as the longer viscera, particularly the heart and symptoms. For instance, it is estimated survival period of the gonococcus great vessels. that up to 60 per cent of women and in a tropical environment, account for In the developed world, the esti­ up to ten per cent of men with gonor­ this high incidence in the developing mated incidence has dropped consid­ rhoea have few , if any, symptoms. countries. erably, especially the late manifesta­ Various other complications requir­ tions, since the introduction of penicil­ ing extensive medical care may de­ lin. Yet syphilis follows gonorrhoea velop in both sexes. In males, they and chickenpox as the third most fre­ include urethral stricture, obstructive quently reported communicable dis­ maladie sterility and so-called " watering-can ease in the United States, with an transmise perineum " - with multiple perineal estimated incidence of four to six cases sexuellement abscesses rupturing and discharging per 10,000, while in the United King­ pus through the perineal skin. In dom the incidence is about one case 873-3310 females , pelvic inflammatory disease per 10 ,000. codapltone (PID), tubal blockage and infertility The overall picture in developing are frequently seen, especially in the countries, especially in tropical Africa, developing world. As much as 30 to is unclear to say the least, to judge by 40 per cent of infertility in women, the available statistical data. The gen­ Poster advising where to ring in case of VD, particularly in Africa, is a result of in Montreal, Canada. eral consensus, however, is that the blockage of the fallopian tubes follow­ prevalence of infectious syphilis is Photo WHO ing gonococcal PID. Apart from the much higher since very high rates have personal anguish resulting from these been reported in many large towns of Another complicating factor is the conditions, infertility-especially in Africa. recent development of antibiotic-re­ tropical Africa-means terrible humili­ Fortunately, reliable methods of sistant strains of the gonococcus. Such ation and loss of social identity. diagnosis are available and so is anti­ " super-strains " have now invaded vir­ Reports have been published of cer­ biotic treatment. Late complications tually every part of the globe, account­ tain African villages where children of venereal syphilis may be relatively ing for 40 per cent of all gonococcal are hardly seen around because less of a problem today than they were strains in the Far East and between 50 the women have been sterilised by in the pre-antibiotic era, but they still and 80 per cent in Nigeria. While the gonorrhoea ! constitute a problem in certain sectors immediate consequence is the need for Prevention of this malady depends of the population. The strategy should more expensive antibiotics for effec­ on early diagnosis and effective treat­ be to maintain vigilance in detecting, tive treatment, there has been an in­ ment of patients and contacts as well treating and preventing the early crease in complications. Most of the as proper health counselling. The use forms of the disease. effective antibiotics are either not of condoms, diaphragms and cervical Gonorrhoea is sometimes referred readily available in developing coun­ caps or of various spermicidal and to as "the drip", "clap", or " the tries or are too expensive and out of bactericidal agents may have some bug " . Few countries have reporting reach for an average patient. As a benefit, and to a lesser extent so may systems that permit an accurate esti­ result, quacks and native healers are the act of urinating, washing or douch­ mate of the true incidence of gonor­ having a field day ! ing after sexual intercourse. The use of rhoea. It is already the most frequently One of the serious consequences of prophylactic antibiotics immediately reported communicable disease in the untreated gonorrhoea in the mother is before or soon after sexual intercourse United States, and persistent high inci­ eye infection in newborn infants, and is common practice in some develop­ dence levels are reported from Euro­ of more recent concern is the develop­ ing countries, but has obvious disad­ pean countries as well. In the develop­ ment of conjunctivitis not only in in­ vantages and should be discouraged. ing world, the situation is even more fants but also in adults due to the Perhaps in this unending race between frightening ; in parts of some African resistant gonococcus. By the time such humans and the gonococcus, the best

6 W oRLD HEALTH , November 1986 Syphilis and gonorrhoea have company hope lies in the development of an Group B streptococcus gives rise to alis, and anaerobic organisms (bacte­ effective vaccine as prophylaxis. febrile sepsis in the mother and rial vaginosis). Studies across Africa Other STDs. Few people would neonatal sepsis in the child. This or­ indicate that 10 to 30 per cent of have imagined a decade or two ago ganism has gained wide recognition women are infected with Trichomonas the extent to which such traditional recently, particularly in the developed vaginalis, a small parasite of the vagin­ venereal diseases as syphilis and countries. al cavity which is almost always sexu­ gonorrhoea have been overshadowed "Tropical venereal diseases" com­ ally transmitted and may cause severe by a " second generation" of STDs. prise lymphogranuloma venereum discharge and discomfort to the in­ And these are now not only more (LGV), chancroid and Donovanosis fected woman. Men function as a widespread but also more difficult to (granuloma inguinale). LGV initially transmitter of the parasite but rarely diagnose and manage. appears as a transient genital sore develop symptoms. Chlamydia trachomatis is one mi­ associated with the matting together Scabies caused by mites and cro-organism that has been associated and swelling of the inguinal lymph pediculosis of the genital region -louse with many disease conditions, includ­ glands. In late stages, with the chronic infestation-may be sexually transmit­ ing non-specific urethritis, now as ted. And unorthodox sexual practices common if not commoner than gonor­ have further expanded the spectrum of rhoea in many parts of the world. It STDs to include diseases such as also affects the testes, eyes and joints, shigellosis, amoebiasis and giardiasis. and causes virtually the same compli­ Acquired Immunodeficiency Syn­ cations as those associated with the drome (AIDS): this apparently new gonococcus. disease labelled by journalists as Mycoplasma and Ureaplasma "Killer Sex Disease" is currently oc­ urealyticum also produce urethritis, cupying the front pages of most news­ but their importance lies in the fact papers all over the world. Many cases that they attach themselves to sper­ have been documented in both de­ matozoa and may inhibit conception ; veloped and developing societies. in women, they have been associated More than 14 African countries have with abortion or still-birth. now been epidemiologically linked Herpes genitalis is a disease that has with the disease and there is alarm that rapidly become more widely recog­ it may spread to other areas. The main Laboratory producing drugs to treat STDs. nised. It is probably the commonest feature of this disease is that it des­ cause of genital ulceration in de­ Photo W HOfT. Farkas troys the body's natural immunity, veloped countries and is now found leaving the victim highly susceptible to with increasing frequency also in de­ involvement of lymphatic channels, it simple infections which are normally veloping countries. It gives rise to gives rise to " elephantiasis" -massive repulsed without harm. While the ma­ painful superficial sores, often self­ enlargement of the lower limbs re­ jority of cases in the "Western" world limiting but recurrent, and may also sembling those of an elephant and are linked with homosexuals and in­ cause severe illness and even death in destruction of the external genitalia. travenous drug users, on the African newborn infants. Chancroid is the commonest type of continent heterosexual transmission is Cytomegalovirus is another virus genital ulceration in some tropical the usual mode of infection. AIDS has that can be sexually transmitted and is African countries, especially in East now become one of the most serious a cause of congenital malformations. Africa. One local community in communicable diseases to threaten The contribution of sexual transmis­ Nigeria calls it " the cut-cut" because mankind, and is certainly the most sion to the spread of this infection in it damages the penis and is greatly serious STD. tropical countries is not yet clearly feared. Donovanosis, a granulomatous Sexually transmitted diseases pose known. lesion capable of extensive destruction major public health problems all over Genital warts are also viral infec­ of the genitalia in both sexes, is more the world. Unfortunately social taboos tions, and may involve the external commonly seen in India, South-East about even discussing them, let alone genitalia as well as the internal struc­ Asia, New Guinea, Central Africa and controlling and preventing them, act tures such as the vagina, cervix and Central and South America. Though as a powerful brake on the energetic urethra. Although of low infectivity, these three diseases are very prevalent counter-action that needs to be taken. they have the capability of becoming in developing countries, very little is Only by facing frankly the less palat­ massive, causing destruction of the being done to control them. able facts of human nature, and by genitalia or obstruction of the birth Vaginal discharge is a common and recognising the vast scale of problems canal in pregnant women. In African important problem with the female that are all too often "swept under the women, the virus has been associated population. It is a world-wide problem carpet", can health care providers and with cancer of the cervix-the com­ whose causative agents may be yeasts consumers alike give adequate priority monest cancer among the female ( candidosis), Trichomonas vaginalis and provision to controlling and pre­ population in Africa. (trichomoniasis) , Gardnerella vagin- venting these diseases. •

W oRLD HEALTH , November 1986 7